Mucosal perforators and mucosal perforasomes from the facial artery. Posible clinical uses and refinements in the harvesting perfofator flap techniques.
Mauricio Enrique Coronel-Banda
ADVERTIMENT. L'accés als continguts d'aquest document i la seva utilització ha de respectar els drets de la persona autora. Pot ser utilitzada per a consulta o estudi personal, així com en activitats o materials d'investigació i docència en els termes establerts a l'art. 32 del Text Refós de la Llei de Propietat Intel·lectual (RDL 1/1996). Per altres utilitzacions es requereix l'autorització prèvia i expressa de la persona autora. En qualsevol cas, en la utilització dels seus continguts caldrà indicar de forma clara el nom i cognoms de la persona autora i el títol. No s'autoritza la seva reproducció o altres formes d'explotació efectuades amb finalitats de lucre ni la seva comunicació pública des d'un lloc aliè. Tampoc s'autoritza la presentació del seu contingut en una finestra o marc aliè a RECERCAT (framing)
ADVERTENCIA. El acceso a los contenidos de este documento y su utilización debe respetar los derechos de la persona autora. Puede ser utilizada para consulta o estudio personal, así como en actividades o materiales de investigación y docencia en los términos establecidos en el art. 32 del Texto Refundido de la Ley de Propiedad Intelectual (RDL 1/1996). Para otros usos se requiere la autorización previa y expresa de la persona autora. En cualquier caso, en la utilización de sus contenidos se deberá indicar de forma clara el nombre y apellidos de la persona autora y título. No se autoriza su reproducción u otras formas de explotación efectuadas con fines lucrativos ni su comunicación pública desde un sitio ajeno. Tampoco se autoriza la presentación de su contenido en una ventana o marco ajeno a RECERCAT (framing). !! ! DOCTORAT'EN'RESERCA'EN'SALUT' ' ' Thesis'Supervisors' ' Professor'PH.'D'José'María'Serra'Renom' PH'D.'Marian'Lorente'Gascón' ' ' ' MUCOSAL'PERFORATORS'AND'MUCOSAL' PERFORASOMES'FROM'THE'FACIAL'ARTERY.' POSSIBLE'CLINICAL'USES'AND'REFINEMENTS'IN' THE'HARVESTING'PERFORATOR'FLAP'TECHNIQUES.'''''' .' ' Ph.'D.'Student' Mauricio'Enrique'CoronelNBanda' !
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MUCOSAL!PERFORATORS!AND!MUCOSAL!PERFORASOMES! FROM!THE!FACIAL!ARTERY.!POSSIBLE!CLINICAL!USES!AND! REFINEMENTS!IN!THE!HARVESTING!PERFORATOR!FLAP! TECHNIQUES.!
Universitat*internacional*de*Catalunya*
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! ! ! Thesis!Supervisors! ! Professor!PH.!D!José!María!Serra!Renom! ! PH!D.!Marian!Lorente!Gascon! ! ! ! MUCOSAL!PERFORATORS!AND!MUCOSAL!PERFORASOMES! FROM!THE!FACIAL!ARTERY.!POSSIBLE!CLINICAL!USES!AND! REFINEMENTS!IN!THE!HARVESTING!PERFORATOR!FLAP! TECHNIQUES.! .! ! ! ! Ph.!D.!Student! Mauricio!Enrique!CoronelOBanda! ! ! ! MarchO2016!
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Doctorat!En!Recerca!En!Salut! ! !
! ! ! Thesis!Supervisors! ! Professor!PH.!D!José!María!Serra!Renom! ! PH!D.!Marian!Lorente!Gascon! ! ! ! MUCOSAL!PERFORATORS!AND!MUCOSAL!PERFORASOMES! FROM!THE!FACIAL!ARTERY.!POSSIBLE!CLINICAL!USES!AND! REFINEMENTS!IN!THE!HARVESTING!PERFORATOR!FLAP! TECHNIQUES.! .! ! Ph.!D.!Student! Mauricio!Enrique!CoronelOBanda! ! ! ! March!O2016
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TABLE OF CONTENTS
TABLE&OF&CONTENTS&...... &5!
TABLE&OF&FIGURES&...... &7!
ABSTRACT&...... &9!
INTRODUCTION&...... &11!
DEFINITION!OF!NEW!TERMS!...... !13!
CLINICAL!USE!IN!SEPTAL!PERFORATION!SECONDARY!TO!COCAINE!ABUSE.!...... !13!
HYPOTHESIS&...... &15!
OBJECTIVES&...... &17!
MATERIAL&AND&METHODS.&...... &19!
CADAVERS!...... !19!
MUCOSAL(PERFORATOR(GROUP(...... (19!
INJECTION!OF!LATEX!...... !20!
DESCRIPTIVE!ANATOMY!...... !21!
MUCOSAL(PERFORASOMES(GROUP(...... (22!
DESCRIPTIVE!ANATOMY!...... !24!
SELECTIVE!INK!INJECTIONS!...... !26!
MEASUREMENTS(...... (27!
STATISTICAL(ANALYSIS(...... (27!
FLAP!HARVESTING!...... !28!
DEFINITION!OF!THE!TERM!MUCOSAL!PERFORASOMES.!...... !29!
CLINICAL!USE!IN!SEPTAL!PERFORATION!SECONDARY!TO!COCAINE!USE.!...... !29!
RESULTS&...... &35!
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CADAVERS!...... !35!
MUCOSAL(PERFORATOR(GROUP(...... (35!
MUCOSAL(PERFORASOMES(GROUP(...... (37!
FLAP!HARVESTING!...... !43!
STATISTICAL!ANALYSIS!...... !47!
MUCOSAL!PERFORATOR!GROUP!...... !47!
MUCOSAL!PERFORASOMES!GROUP!...... !48!
DEFINITION!OF!THE!TERM!MUCOSAL!PERFORASOMES.!...... !49!
CLINICAL!USE!IN!SEPTAL!PERFORATION!SECONDARY!TO!COCAINE!ABUSE.!...... !50!
DISCUSSION&...... &53!
MUCOSAL!PERFORATORS!AND!MUCOSAL!PERFORASOMES!...... !53!
DEFINITION!OF!NEW!TERMS!...... !58!
CLINICAL!USE!IN!SEPTAL!PERFORATION!SECONDARY!TO!COCAINE!ABUSE.!...... !59!
OTHER!POSSIBLE!CLINICAL!USES!...... !60!
CONCLUSIONS&...... &61!
REFERENCES&...... &63!
DEDICATION&AND&ACKNOWLEDGEMENTS&...... &67!
ARTICLES&...... &69!
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TABLE OF FIGURES
FIGURE!!1!EXPOSURE!OF!ORAL!MUCOSA!...... !20!
FIGURE!!2!EXPOSURE!OF!FACIAL!ARTERY!...... !21!
FIGURE!!3!EXPOSURE!O!FACIAL!ARTERY!AND!THEIR!MUCOSAL!PERFORATORS! 22!
FIGURE!!4!DISSECTION!DESIGN!!...... !23!
FIGURE!!5!DISSECTION!HARVESTING!OF!THE!SKIN!FLAP!...... !24!
FIGURE!!6!DISSECTION!LANDMARK!POINTS!...... !25!
FIGURE!!7!SELECTIVE!INK!INK!INJECTIONS!...... !26!
FIGURE!!8!IDENTIFICATION!OF!A!MUCOSAL!PERFORASOME!...... !27!
FIGURE!!9!IDENTIFICATIONS!OF!THE!FACIAL!ARTERY!BY!DOPPLER!...... !30!
FIGURE!!10!MARKING!OF!THE!FACIAL!ARTERY!ON!THE!FACE!...... !31!
FIGURE!!11!FLAP!HARVESTING!FOR!A!NASAL!SEPTAL!DEFECT!...... !32!
FIGURE!!12!INSERTION!OF!THE!FLAP!IN!THE!SEPTAL!DEFECT!...... !33!
FIGURE!!13!DIAGRAM!OF!THE!ORAL!MUCOSAL!!PERFORASOMES!...... !41!
FIGURE!14!IDENTIFICATION!OF!TWO!PERFORASOMES………………………………..….!41! FIGURE!!15!IDENTIFICATION!OF!FIVE!PERFORASOMES!...... !43!
FIGURE!!16!FLAP!DESIGN!IN!CADAVER!...... !44!
FIGURE!!17!FLAP!DESIGN!IN!CADAVER!FOR!LIPS!...... !44!
FIGURE!!18!FLAP!DESIGN!IN!CADAVER!FOR!THE!PALATE!...... !45!
FIGURE!!19!REVERSE!FLOW!FLAP!DESIGN!!...... !45!
FIGURE!!20!REVERSE!FLOW!FLAP!DESIGN!FOR!THE!NASAL!SEPTUM!...... !46!
FIGURE!!21!REVERSE!FLOW!FLAP!DESIGN!FOR!THE!!CONJUNCTIVA!...... !46!
FIGURE!!22!RELATION!BETWEEN!ORIGIN!AND!LENGHT!...... !47!
FIGURE!!23!RELATION!BETWEEN!ARTERIAL!DIAMETERS!...... !48!
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FIGURE!!24!RELATION!BETWEEN!PERFORATORS!AND!PERFUSED!AREAS!...... !49!
FIGURE!25!CLINICAL!CASE...... ………………………………………………….51!
FIGURE!26!CLINICAL!CASE!EVOLUTION!………...... ………………………….………….51! FIGURE!!27!CLINICAL!CASE!FOLLOW!UP!...... !52!
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ABSTRACT
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BACKGROUND:!Neither!the!oral!mucosal!perforators!of!the!facial!artery!nor!the! mucosal perforasomes they!perfused!have!been!described.!!
Septal! perforation! is! a! frequent! complication! of! snorting! cocaine.! Its! reconstruction! usually! requires! complex! procedures! based! on! oral! mucosa! or! distant!flaps.!
METHODS:!We!studied!30!facial!arteries.!The!first!ten!were!injected!with!latex,!! and!their!diameter!and!length!were!measured.!!All!perforators!extending!from!the! facial!artery!and!heading!directly!to!the!oral!mucosa!were!selected.!The!remaining! twenty!arteries!were!dissected.!Perforators!larger!than!0.5!mm!were!selected!and! their! diameters! were! measured;! the! distance! between! their! exit! point! over! the! facial!artery!and!the!branchingOoff!point!from!the!superior!labial!artery!was!also! measured.!!The!selected!perforators!were!injected!with!1!cc!of!diluted!ink.!Both! labial!arteries!were!ligated!to!limit!the!study!to!the!mucosal!perforators!from!the! facial!artery.!The!results!were!analyzed!statistically.!Systematic reviews of PubMed and the Cochrane Library were performed in search of articles describing mucosal perforators or mucosal perforasomes.
We! describe! a! reconstruction! of! a! septal! defect! caused! by! cocaine! abuse! in! five! patients! ! using! a! flap! based! on! mucosal! perforasomes! (MBPF)! from! the! facial! artery.!
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RESULTS:! From! the! specimens! with! latex,! 52! oral! mucosal! perforators! were! analyzed.!The!mean!diameter!was!0.50!mm!and!the!mean!number!per!facial!artery! was!5.2.!The!mean!length!was!16.42!mm.!!
SeventyOfour!perforators!from!20!hemifaces!were!inkOinjected;!the!mean!diameter! was!0.58!mm,!and!the!mean!number!per!artery!was!3.7.!The!mean!area!perfused! by! each! perforator! was! 274.71! sq.! mm.! Six! types! of! mucosal! perforasomes! dependent!on!facial!artery!perforators!were!identified.!
MBPF!obtains!satisfactory!results!in!reconstruction!once!the!patient!abandons!the! cocaine!habit.!
CONCLUSIONS:!Most!of!the!mucosal!perforators!of!the!facial!artery!are!found! between!the!branchingOoff!points!of!the!inferior!and!superior!labial!arteries.!!
To our knowledge, the concepts of mucosal perforators and mucosal perforasomes have not been described to date. Flaps! based! on! mucosal!perforasomes! from! the! facial! artery!are!useful!for!the!reconstruction!of!septal!perforation!due!to!cocaine!abuse and may open up promising new areas of research.
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INTRODUCTION
In!many!fields!of!surgery!there!are!obstacles!that!interfere!with!our!global!vision!of! a!problem,!or!the!state!of!the!art!does!not!allow!us!to!imagine!the!global!picture.!
We!can!erroneously!assume!that!something!does!not!exist.!In!the!same!way,!we! could! assume! that! the! simple! observation! of! a! phenomenon! explains! all! the! possibilities.! Like! Aristotle's! assumption! that! the! speed! of! falling! bodies! is! proportional! to! their! weight,! which! was! later! refuted! by! Galileo! (1).! In! the! scientific! method! ! we! need! to! demonstrate! our! hypothesis,! as! Descartes! claims!
“Never(to(accept(anything(for(true(which(I(did(not(clearly(know(to(be(such;(that(is(to( say,(carefully(to(avoid(precipitancy(and(prejudice,(and(to(comprise(nothing(more(in( my( judgment( than( what( was( presented( to( my( mind( so( clearly( and( distinctly( as( to( exclude(all(grounds(of(doubt.”!.!(2)!
Quoting! D.H.! Lawrence’s! Lady! Chatterley’s! Lover! (3):! “What! the! eye! doesn’t! see! and!the!mind!doesn’t!know,!doesn’t!exist”.!!
The! reconstruction! of! the! oral! mucosa! is! an! area! of! interest! to! facial! surgeons,! including! maxillofacial,! plastic,! reconstructive! and! oncologic! surgeons.! The! reconstruction!of!defects!in!the!oral!and!nasal!cavity!presents!many!challenges!to! be!overcome.!We!need!a!soft,!pliable!and!thin!tissue!to!replace!the!defect!caused!by! various! noxious! agents.! ! Many! diverse! solutions! have! emerged! to! restore! this! complex!area.!Many!of!them!have!failed!because!of!lack!of!similarity!on!the!tissue! used!to!perform!a!restoration!of!the!defect.!!!!
Reconstructive! surgery! has! evolved! considerably! since! the! introduction! of! perforator!flaps,!(4)!which!have!been!described!in!detail!in!recent!years.!(5O8)!The!
! ! 11! ! development! of! perforator! flaps! allows! the! performance! of! singleOstage! surgery! and! the! extraction! of! madeOtoOmeasure! flaps.! But! until! now! the! interest! has! focused! on! the! perforators! that! end! on! the! skin.! Even! though! we! suspect! of! the! existence! of! perforators! to! the! oral! mucosa,! we! should! demonstrate! them! and! describe!their!existence.!
Hallock!(12)!proclaims!that!a!cutaneous(perforator!is!any!vessel!that!perforates!the! outer! layer! of! the! deep! fascia! to! supply! the! overlying! skin! and! subcutaneous! tissues.!!Moreover,!the!use!of!the!term!"perforator!flap"!is!still!controversial.!(9).!
According!to!the!Ghent!consensus!study!(10),!"a!perforator!flap!is!a!flap!consisting! of! skin! and/or! subcutaneous! fat.! The! vessels! that! supply! blood! to! the! flap! are! isolated!perforator!(s).!These!perforators!may!pass!either!through!or!in!between! the!deep!tissues!(mostly!muscle)."!The!study!also!states!that,!even!if!the!skin!is!not! included,!the!flap!can!be!formed!by!Scarpa's!fascia!and!subcutaneous!fat.!
Hofer’s! classical! description! of! facial! artery! perforator! flaps! was! limited! to! perforators!leading!to!the!skin.!(8).!The!current!definitions!of!perforator!flaps!do! not!include!those!that!terminate!in!the!mucosa,!but!only!those!that!end!in!the!skin.!
(11O13)!
Furthermore,!the!use!of!oral!mucosal!flaps!from!the!internal!side!of!the!cheek!area! to!reconstruct!oral!defects!has!been!well!described!by!many!authors.!(14O17)!All! these!flaps!are!based!on!the!facial!artery!and!its!branches.!However,!their!vascular! territories!have!not!been!established.!!
Qassemyar,! et! al.! (18)! have! described! the! cutaneous! territories! perfused! by! perforators! from! the! facial! artery.! ! However,! the! facial! artery! perforators! of! the!
12! ! ! ! oral!mucosa!and!the!intraoral!mucosal!territories!dependent!on!these!perforators! have!not!been!described.!
DEFINITION OF NEW TERMS
In! the! Medical! literature! we! found! no! references! to! mucosal! perforators! or! mucosal! perforasomes.! Perforators! are! penetrating! arteries! that! emerge! from! a! main!vessel,!pass!through!the!muscle!or!another!anatomic!structure!and!reach!the! skin! or! subcutaneous! tissue! (9O13).! Perforators! and! perforasomes! have! been! described!in!other!areas!but!none!of!the!current!definitions!identify!the!mucosa!as! a!final!destination!of!a!perforator!artery.!!
CLINICAL USE IN SEPTAL PERFORATION SECONDARY TO
COCAINE ABUSE.
In!relation!to!the!reconstruction!of!nasal!septal!defects!we!should!remember!that,& after!cannabis,!cocaine!is!the!most!commonly!used!drug!in!Europe!(56,57).!!!The! prevalence!of!cocaine!use!in!Spain!in!2011!was!2.2%.!(58).!It!is!mainly!consumed! by!younger!age!groups!(59).!!!
The!harmful!effects!of!cocaine!use!are!wellOestablished.!Special!emphasis!has!been! placed!on!its!damage!to!the!brain!and!cardiovascular!system!(19,!20).!Damage!to! the!central!facial!region!due!to!cocaine!use!has!been!reported,!but!its!management! is!complicated!and!is!always!multidisciplinary!(21O24).!
The!approach!to!repairing!the!defects!caused!by!cocaine!depends!on!their!size.!A! wide! range! of! defects! has! been! described,! from! simple! perforations! to! regional! midface!necrosis!(27,30,31,60,!61).!
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Septal! perforation! is! a! complication! of! cocaine! snorting! (25,! 26).! Other! causes! reported! include! inhaled! irritants! such! as! chromium! (27),! systemic! diseases,! chronic!infections!(28)!and!even!cancer!chemotherapy!(29).!Mucosal!defects!range! from!a!clinically!asymptomatic!state!through!pinpoint!holes!to!the!destruction!of! the!nasal!support!causing!depression!of!the!dome!and!sinking!of!the!nasal!septum! or!"saddle!nose",!or!even!the!destruction!of!the!maxilla!(30,!31).!!
Although! some! authors,! such! as! Mullace! et! al.,! reported! the! use! of! prosthetic! buttons! for! small! and! mediumOsized! perforations! (62),! other! studies! have! found! that!they!are!poorly!tolerated!in!up!to!50%!of!cases!(63).!Various!types!of!local!flap! have!been!tested.!!However,!because!of!the!high!risk!of!failure!due!to!damage!to! adjacent!tissue,!the!use!of!distant!tissues!or!even!distant!free!flaps!is!preferred!(65,!
66).!The!problem!with!remote!or!free!flaps!is!that!their!volume!may!be!excessive!
(31,! 65)! and! reconstruction! may! be! unsatisfactory! due! to! the! obstruction! to! the! passage!of!air.!In!this!case!local!or!distant!flaps!based!on!perforators!that!supply! similar! tissues! could! provide! the! best! solution! in! order! to! achive! a! satisfactory! reconstruction!.!
With!this!study!we!aim!to!characterize!the!perforators!from!the!facial!artery!to!the! oral!mucosa!of!the!cheek,!to!describe!their!nature!and!to!measure!not!only!their! anatomical! aspects! but! also! their! functional! territories! in! order! to! facilitate! the! restoration!of!different!defects!on!the!oral!and!nasal!cavity.!!We!also!believe!this! new!knowledge!could!enlight!the!!physiology!!of!the!mucosal!territories!in!other! body!lining!segments!such!as!in!the!vaginal,!uretral,!intestinal!mucosa!or!others.!!!
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HYPOTHESIS
Does!the!oral!mucosa!of!the!cheek!have!direct!perforators!arising!from!the!facial! artery!?!!
Null!Hypothesis!
The!oral!mucosa!of!the!cheek!does!not!have!direct!perforators!arising!!from!the! facial!artery.!
Alternative!Hypothesis.!
The!oral!mucosa!of!the!cheek!has!direct!perforators!arising!from!the!facial!artery.!
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OBJECTIVES
The!objectives!of!this!study!are:!
!To!identify!the!existence!of!direct!perforators!that!have!their!origin!in!the!facial! artery!on!the!way!to!the!oral!mucosa!of!the!cheek.!!
!To! determine! the! configuration! of! those! perforators! that! is:! their! number,! diameter!and!length,!and!their!distribution!in!relation!to!the!facial!artery.!
To!describe!the!oral!mucosal!territories!perfused!by!perforators!derived!from!the! facial!artery.!
To!define!a!new!term!to!!denominate!the!oral!mucosal!territories!perfused!by!a! direct!perforator!from!an!artery.!
To!detail!the!oral!mucosal!territories!perfused!by!perforators!from!the!facial!artery! commenting! on! their! number,! location,! the! mean! perfused! area! and! their! distribution.!
To!redesign!currently!used!flaps!for!reconstruction!of!the!oral,!nasal!and!facial! mucosas!based!on!the!knowledge!!of!the!!perforators!and!their!territories.!
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MATERIAL AND METHODS.
For!this!study!we!selected!freshOfrozen!heads!from!the!department!of!!donation!of! cadavers!from!the!Universitat!Internacional!de!Catalunya.!We!used!complete!heads!! that! had! an! intact! oral! mucosa! and! had! not! been! used! for! arterial! ! or! venous! studies.! We! discarded! incomplete! specimens! or! those! which! had! been! altered! during!manipulation!in!our!focus!study!areas.!
Fifteen! different! heads! of! freshOfrozen! cadavers! were! used,! divided! into! two! groups:! one! with! five! heads! or! ten! hemifaces! that! we! call! “mucosal! perforator! group”! and! the! other! with! ten! faces! or! twenty! hemifaces! that! we! call! “mucosal! perforasomes!group”.!
Each!hemiface!in!the!mucosal!perforator!group!was!dissected!and!the!perforators! of! the! oral! mucosa! of! the! cheek! extending! from! the! facial! artery! (previously! injected!with!latex)!were!identified.!
In! the! twenty! hemifaces! in! the! mucosal! perforasome! group,! oral! mucosal! perforators!of!the!facial!artery!larger!than!0.5!mm!were!perfused!with!diluted!ink;! the!facial!artery!was!dissected!from!the!base!of!the!jaw!as!far!as!the!branchingOoff! point!from!the!upper!labial!artery.!
CADAVERS
MUCOSAL PERFORATOR GROUP
A! submandibular! incision! was! made! 2! cm! below! the! lower! edge! of! the! jaw.! The! facial! artery! and! vein! were! identified! at! the! level! of! their! branchingOoff! points! below!the!edge!of!the!jaw.!
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INJECTION OF LATEX
Arterial!lavage!was!performed!with!30cc!of!0.9!saline!solution,!and!two!incisions! were!made!at!the!nasal!philtrum!to!verify!fluid!outflow.!!After!that,!approximately!
4cc!of!LME/R1!latex!(Latex!Compound!Spanish!SA!Sabadell)!was!injected,!until!it! was! seen! out! via! the! nasal! incisions.! The! excess! was! removed! and! the! sample! underwent!freezing!at!!O13!°!C!for!24!hours.!
!
FIGURE 1
Blue*latex*specimen.*Midline*incision*in*the*chin*and*exposure*of*oral*mucosa.*Note*the* origin*of*the*facial*artery*(black*arrowhead).** ! An!incision!was!made!in!the!midline!of!the!lower!lip!and!chin!(Figure!01).!In!the! oral! mucosa! at! the! level! of! the! gingival! sulcus! a! flap! was! lifted! including! the! periosteum! and! reaching! the! sphenomandibular! ligament! (Figure! 02).! The!
20! ! ! ! dissection!was!submucosal!in!order!to!reveal!the!perforators!extending!from!the! facial!artery!to!irrigate!the!oral!mucosa.!
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FIGURE 2!
Blue*latex*specimen*.*Facial*artery*dissection*and*facial*artery*exposure.*The*green*point* corresponds*with*the*oral*commisure.* &
DESCRIPTIVE ANATOMY
The!facial!artery!was!identified!at!its!exit!point!from!the!mandibular!branch.!The! dissection!proceeded!in!antegrade!fashion!from!the!artery!to!the!mucosa!up!to!its! anastomosis!with!the!angular!artery!or!its!termination.!
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The!diameter!of!the!artery!was!measured!at!the!base!of!the!jaw.!Dissection!was! performed!to!identify!and!preserve!the!oral!mucosal!perforators,!as!well!as!their! origin!over!the!facial!artery,!taking!the!base!of!the!jaw!as!a!reference.!(Figure!03)!
!
FIGURE 3&
Pink*latex*specimen.*Exposure*of*facial*artery*and*their*mucosal*perforators*(black*arrows).* Note*the*branchingEoff*site*of*the*superior*labial*artery*and*the*inferior*labial*artery*(empty* arrowheads),*and*the*emergence*of*the*facial*artery*(double*black*arrowheads).* ! The!perforators!from!the!upper!and!lower!labial!arteries!were!not!examined.!
MUCOSAL PERFORASOMES GROUP
The! skin! incisions! were! made! following! a! facelift! pattern.! Two! incisions! were! added,!the!mucosal!perforator!from!one!of!a!"crow's!foot"!to!the!ipsilateral!tragus,! and! the! second! one! four! finger! widths! below! the! horizontal! branch! of! the! mandible.!(Figure!04)!
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FIGURE 4&
Preauricular*flap*design*with*a*superior*extension*to*the*orbital*rim*and*an*inferior*line* below*the*inferior*mandible*line.* !
We!performed!a!supraOSMAS!dissection!and!all!superficial!perforators!that!could! be!identified!were!ligated.!In!this!way,!all!the!mucosal!perforators!were!preserved.!
(Figure!05)!
! ! 23! !
!
FIGURE 5&
Raising*of*skin*flap*and*ligation*of*cutaneous*perforators.*In*green,*the*oral*commisure*is* marked.* ! The!inferior!and!superior!labial!arteries!were!ligated!after!identification.!!
DESCRIPTIVE ANATOMY
The!length!of!the!facial!artery!was!measured!from!the!lower!edge!of!the!jaw!until! the!exit!point!of!the!superior!labial!artery.!The!diameter!of!the!facial!artery!was! measured! at! three! levels:! the! base! of! the! jaw,! the! oral! commissure! and! the! exit! point! of! the! superior! labial! artery.! The! number! of! oral! mucosal! perforators! was! identified,!as!was!their!origin!over!the!facial!artery,!taking!the!branchingOoff!site!of! the!superior!labial!artery!as!a!starting!point!(Figure!06)!!
24! ! ! !
!
FIGURE 6&
Dissection*of*the*facial*artery*tree*and*identification*of*its*branches*and*perforators.*In* yellow,*the*gonion*(G),*pogonion*(P),**in*green,*the*oral*commissure*(O).* !
For!identification,!three!points!were!taken!as!landmarks:!the!gonion,!the!pogonion,! and!the!oral!commissure.!A!line!was!traced!between!gonion!and!pogonion!at!the! base!of!the!jaw,!and!another!parallel!line!from!the!oral!commissure.!
! ! 25! !
SELECTIVE INK INJECTIONS
!
FIGURE 7!
The*selected*perforators*were*closed*with*clamps*and*diluted*ink*was*used.* !
Perforators! larger! than! 0.5! mm! were! selected! and! were! perfused! with! 1cc! of! diluted! ink! (Figure! 07)! After! each! injection;! the! presence! of! coloring! in! the! oral! mucosa! was! examined.! (Figure! 08)! If! coloring! was! observed,! the! area! was! identified! and! measured.! Different! colors! were! used! to! distinguish! each! area!
(Gouache;!Royal!Talens,!Apeldoorn,!Netherlands).!
26! ! ! !
!
FIGURE 8&
Identification*and*measuring*of*a*specific*area*on*the*oral*mucosa*(white).*We*used*the*ruler* as*a*patron*to*obtain*a*scale*that*can*be*used*on*the*image*processor.*We*can*see*four* mucosal*perforasomes* MEASUREMENTS
The!Image!J!software!version!1.45s!was!used!(W.!S.!Rasband,!ImageJ,!U.S.!National!
Institutes!of!Health,!Bethesda,!Md.,!http://rsb.info.nih.gov/ij)!
The!measurements!were!made!with!two!photographs!taken!at!a!distance!of!30!cm! from!the!specimen.!After!obtaining!the!scale!and!the!conversion!rate,!the!program! converted!the!measurements!into!the!distances!or!areas!registered.!!
STATISTICAL ANALYSIS
We! used! the! STATA! program! version! 11.1(Lakeway! Drive,! Texas,! USA).! The!
Shapiro! Wilk! test! and! the! normal! probability! plot! technique! were! performed! to!
! ! 27! ! assess! the! normality! of! the! variables.! If! the! distribution! of! the! variables! was! normal,! the! Pearson’s! test! was! used.! When! distribution! was! nonOnormal,!
Spearman's!rank!correlation!coefficient!was!used!to!evaluate!the!results.!A!p!<0.05! was!considered!to!indicate!statistical!significance!in!all!cases.!
To!determine!the!branchingOoff!sites!of!the!superior!and!inferior!labial!arteries,!the! guide! points! described! previously! were! used.! Means,! standard! deviations,! and!
95%! confidence! intervals! were! calculated.! Tolerance! limits! were! also! obtained! with!a!95%!confidence!that!95%!of!the!general!population!were!within!the!limits! determined.!!
FLAP HARVESTING
After!the!facial!artery!dissection!and!selective!ink!injections!on!the!20!hemifaces!in! the!mucosal!perforasomes!group!,!the!total!stained!area!was!determined.!With!this! area!two!types!of!musculoOmucosal!flaps!were!made.!The!first!one!was!based!on! the!proximal!facial!artery,!by!ligating!the!facial!artery!just!before!the!branchingOoff! site!of!the!superior!labial!artery!and!including!the!mucosa!and!the!buccinator!or! orbicularis!muscle,!as!appropriate.!The!second,!the!reverseOflow!flap,!was!made!by! sectioning! the! facial! artery! just! after! the! branchingOoff! site! of! the! inferior! labial! artery;! in! the! absence! of! this! artery,! the! facial! artery! was! sectioned! above! the! lower!edge!of!the!stained!oral!mucosa.!
The!arc!of!rotation!of!these!flaps!was!assessed!and!the!anatomical!sites!that!the! flaps!could!reach!to!cover!a!hypothetic!defect!were!identified.!!
!
28! ! ! !
DEFINITION OF THE TERM MUCOSAL PERFORASOMES.
We!performed!a!systematic!review!of!the!literature!through!the!PubMed!database! searching! for! articles! with! the! keywords! "perforator! mucosa",! "mucosal! perforator",! "oral! mucosa! perforator",! "oral! mucosal! perforator",! "oral! mucosa! perforator!flap"!and!"oral!mucosal!perforator!flap".!In!the!articles!found,!we!looked! for!descriptions!of!mucosal!perforators!or!mucosal!perforasomes.!
In! the! same! database! we! searched! for! the! keywords! "perforasome"! and!
"perforasomes".! We! examined! each! of! the! references! to! see! whether! they! described! mucosal! perforator! flaps,! mucosal! perforators,! or! mucosal! perforasomes.!
In!the!Cochrane!Library!we!also!searched!for!the!terms!"mouth!mucosa"!and!"flap! perforators"!to!identify!references.!
CLINICAL USE IN SEPTAL PERFORATION SECONDARY TO
COCAINE USE.
In!a!clinical!setting!we!selected!five!clinical!cases!with!septal!perforations!due!to! cocaine! use.! As! inclusion! criteria! they! reported! quitting! their! noxious! habit.!
FollowOup! was! made! on! the! patients! for! at! least! 6! months.! The! endpoint! was! restoring!of!defect!in!the!nasal!septum.!
! ! 29! !
!
FIGURE 9&
Marking*of*the*facial*artery*on*the*oral*mucosa.*We*use*a*nonEdirectional*Doppler*with*an*8* MHz*probe.* !
Using!a!Doppler!probe,!in!the!oral!mucosa!we!mark!the!path!of!the!facial!artery.!
(Figure!09)!We!make!the!same!mark!on!the!skin!of!the!cheek,!from!the!exit!of!the! artery!at!the!base!of!the!jaw!to!its!termination!in!the!nasal!ala!or!its!anastomosis! with! the! angular! artery.! This! will! help! us! later! in! the! identification! of! the! bifurcation!of!the!superior!labial!artery,!which!will!be!near!the!oral!commissure.!
(Figure!10)!
30! ! ! !
!
FIGURE 10&
Marking*of*the*facial*artery*on*the*cheek*skin*and*the*bifurcation*of*the*superior*labial* artery.*We*start*the*searching*at*a*point*7.4*mm*lateral*and*5.1*mm*above*the*oral* commissure.* !
We!harvest!the!musculoOmucosal!flap!extracting!an!area!about!20%!larger!than!the! defect!that!we!aim!to!cover.!(Figure!11)!We!attempt!to!ligate!the!facial!artery!in!the! gingival!sulcus,!taking!care!not!to!damage!the!perforators!next!to!the!buccinator! and!orbicularis!muscles.!
! ! 31! !
!
FIGURE 11&
Flap*harvested*to*reconstruct*the*septal*defect.*We*select*an*area*20%*larger*than*the*defect* we*intend*to*reconstruct.* !
!
We!perform!a!retrograde!dissection!of!the!facial!artery,!taking!extreme!caution!at! the!branching!off!site!of!the!superior!labial!artery!bifurcation.!!
Once! we! reach! the! bifurcation! of! the! superior! labial! artery! we! ligate! it! and! continue!the!dissection!over!the!facial!artery!to!the!base!of!the!nasal!ala!or!to!a! point!where!we!can!easily!insert!our!flap!inside!the!nose.!
An!incision!is!made!at!the!base!of!the!nasal!ala!on!the!alar!margin!to!allow!correct! placement!of!the!flap.!On!the!septal!orifice,!we!excise!the!borders!of!the!defect!until! we! find! healthy! tissue.! If! possible! we! lift! the! septal! periorificial! mucosa! on! the! perimeter!of!the!orifice!5!mm!to!insert!the!flap!facing!the!raw!surfaces.!We!attach! our!flap!with!strategically!placed!sutures!(eight!to!ten!stitches).!(Figure!12)!!
32! ! ! !
!
FIGURE 12&
Insertion*of*the*flap*in*the*septal*defect.* !
At!this!point,!if!required,!we!modify!the!nasal!tip!by!open!rhinoplasty.!Similarly,!if! cartilage! grafts! are! required! for! the! nasal! dorsum,! and! grafts! or! local! plasty! to! release!the!nostrils,!reconstruction!is!performed.!In!one!case!a!local!graft!based!on! the!palatine!artery!was!required!to!cover!a!defect!in!the!palate.!
The! donor! site! is! closed! in! layers! with! absorbable! stitches.! Depending! on! the! amount!of!mucosa!obtained,!this!procedure!may!range!from!a!simple!closure!(the! most!common!case)!to!a!local!VOY!plasty.!
After!surgery!a!standard!splinting!is!applied!to!the!nose!and!a!gauze!is!left!in!place! impregnated!with!antibiotic,!without!compressing!the!flap.!This!gauze!is!removed! within!24!hours.!The!flap!is!evaluated!daily!in!the!first!72!hours.!
! ! 33! !
!
!
34! ! ! !
RESULTS
CADAVERS
The!group!“cadavers”!!includes!!fifteen!heads,!or!thirty!hemifaces!!divided!as! follows:!ten!hemifaces!treated!with!latex!!in!the!“mucosal!perforator!group”;!!and! the!twenty!hemifaces!called!“mucosal!perforasomes!group”,!this!group!was!studied! wih!diluted!ink.!
MUCOSAL PERFORATOR GROUP
In!this!group!with!ten!hemifaces!we!measured!the!diameter!of!the!facial!artery!at! the!base!of!the!mandible,!its!length,!from!its!exit!point!up!to!its!anastomosis!with! the!angular!artery!or!its!termination.!The!total!number!of!mucosal!perforators! found!on!!each!artery!was!registered.!We!measured!each!perforator!and! determined!the!diamenter!at!its!exit!point!!and!!its!length!to!the!mucosa.!!We! verified!in!each!hemiface!the!existence!of!the!superior!labial!artery!and!the!inferior! labial!artery.!
The!mean!diameter!of!the!facial!artery!at!its!base!was!2.47!mm!±!0.32.!Its!mean! length!from!the!base!of!the!jaw!to!its!termination!or!in!its!anastomosis!with!the! angular! artery! was! 119.30! mm! ±! 12.40! mm.! ! FiftyOtwo! oral! mucosal! perforators! from! the! facial! artery! were! found! in! the! ten! hemifaces.! The! mean! number! of! mucosal!perforators!per!facial!artery!was!5.2!±!1.14.!The!mean!diameter!was!0.50! mm!±!0.16,!and!the!mean!length!of!the!perforators!from!their!point!of!emergence! to!the!mucosa!was!16.42!mm!±!5.33.!(Table!01)!
!
! ! 35! !
!
!
Table!01.!Overview!of!facial!artery!and!mucosal!perforators!in!the!Mucosal! Perforator!Group! !
Facial&Artery&Total& Mucosal&Perforators& Dissection&N& Diameter& Diameter& Length& Length&& Number&
1! 2.01! 122.08! 4! 0.57! ±!0.23! 20.28! ±!2.53! 2! 2.55! 107.99! 6! 0.43! ±!0.12! 18.48! ±!7.38! 3! 2.33! 98.86! 7! 0.48! ±!0.23! 11.53! ±!1.51! 4! 2.03! 105.53! 4! 0.41! ±!0.15! 21.67! ±!3.87! 5! 2.53! 130.29! 5! 0.60! ±!0.10! 20.10! ±!2.68! 6! 2.33! 117.51! 7! 0.53! ±!0.12! 10.77! ±!5! 7! 2.39! 134.82! 5! 0.49! ±!0.05! 17.62! ±!1.93! 8! 2.79! 115.90! 4! 0.48! ±!0.10! 14.75! ±!3.91! 9! 2.92! 125.72! 5! 0.59! ±!0.14! 16.07! ±!1.76! 10! 2.83! 134.27! 5! 0.48! ±!0.25! 18.20! ±!6.32! ! ! ! ! ! ! ! ! Mean! 2.47! 119.30! 5.20! 0.50! ! 16.42! ! SD*! 0.32! 12.40! 1.14! 0.16! !! 5.33! !! *&Standard&deviation& & & ! ! ! ! Results&are&expressed&in&millimeters&mean&±&&standard&deviation.& ! ! ! ! !
Most!of!the!mucosa!of!the!cheek!was!perfused!directly!by!perforators!of!the!facial!
artery.!The!mucosa!of!the!lips!was!perfused!by!perforators!from!the!labial!arteries,!
although!these!arteries!were!not!the!subject!of!our!study.!
The!superior!labial!artery!was!found!in!all!cases.!In!two!cases,!the!inferior!labial!
artery!was!not!found;!in!both!these!cases,!the!sublabial!artery!was!identified.!!
&
36! ! ! !
MUCOSAL PERFORASOMES GROUP
In!this!group!with!twenty!hemifaces!we!identified!the!dissection!and!the!sex!of!the!
cadaver.!!We!measured!!the!diameter!of!the!facial!artery,!at!different!levels.!The!
length!of!the!facial!artery!from!the!inferior!border!of!the!jaw!!to!the!exit!point!of!
the!superior!labial!artery.!!We!recorded!also!the!number!of!perforators!larger!than!
0,5!mm!in!diameter!that!arise!from!the!facial!artery!towards!the!oral!mucosa.!!
! ! ! ! ! ! ! ! Table!02.!General!description!of!facial!artery!in!the!Mucosal!Perforasomes! Group! ! FA& FA&diameter& FA&diameter& Length&of&FA&from& DissecW& diameter&at& at&oral& N&of&FAMP&>& Sex& at&origin&SLA& mandible&to&superior& tion&& mandible& commissure& 0.5&mm& (mm)& labial&artery&(mm)& (mm)& (mm)& 1! M! 2.3! 1.9! 0.9! 62.3! 2! 2! M! 2.98! 1.5! 1.25! 52.2! 2! 3! M! 3.65! 1.71! 1.37! 59.05! 2! 4! M! 2.74! 1.91! 0.98! 57.93! 5! 5! M! 2.44! 1.61! 1.25! 63.98! 6! 6! M! 2.55! 1.9! 1.11! 64.58! 5! 7! M! 2.51! 1.62! 1.23! 63.3! 5! 8! M! 2.71! 1.68! 0.96! 64.96! 3! 9! F! 2.86! 1.64! 1.2! 66.22! 3! 10! F! 2.23! 1.76! 1.1! 61.71! 3! 11! F! 2.24! 1.56! 0.97! 65.23! 5! 12! F! 2.51! 1.59! 1.28! 74.77! 3! 13! F! 2.73! 2.03! 1.35! 60.72! 3! 14! F! 2.5! 1.85! 1.7! 58.98! 4! 15! M! 3.06! 1.71! 1.67! 65.19! 4! 16! M! 2.62! 1.63! 1.59! 74.87! 4! 17! F! 3.51! 2.68! 1.58! 67.43! 4! 18! F! 2.67! 1.87! 1.49! 64.27! 5! 19! F! 2.96! 1.61! 1.27! 49.56! 4! 20! F! 3.03! 1.42! 1.39! 56.82! 2! Mean& 2.74! 1.76! 1.28! 62.7! 3.7! ! SD*& !! 0.37! 0.27! 0.23! 6.03! 1.19!
*&Standard&deviation;&FA:&Facial&Artery;&SLA:&Superior&Labial&Artery;&FAMP:&Facial&Artery& Perforators&Mucosal&perforators&measuring&more&than&0.5&mm& !
The!diameter!of!the!facial!artery!was!2.74!±!0.38!mm!at!the!base!of!the!jaw,!1.76!±!
0.27! mm! at! the! oral! commissure,! and! 1.28! ±! 0.24! mm! at! the! bifurcation! of! the!
superior!labial!artery.!The!mean!length!of!the!facial!artery!from!the!base!of!the!jaw!
to!the!point!of!emergence!of!the!superior!labial!artery!was!62.70!±!6.18!mm.!The!
! ! 37! ! mean!number!of!perforators!larger!than!0.5!mm!was!3.70±!1.22.!In!six!cases!we! found!a!fifth!oral!mucosal!perforator,!and!in!one!case!a!sixth!(Table!02).!
As! previously,! we! corroborated! the! existence! of! the! superior! and! inferior! labial! arteries!and!determined!the!exit!point!of!the!superior!labial!artery!based!on!a!line! beginning! on! the! mouth! commissure,! and! parallel! to! the! inferior! border! of! the! mandible.!!!
The!superior!labial!artery!branched!bilaterally!from!the!facial!artery!in!all!cases.!
Taking! the! oral! commissure! as! reference,! the! branchingOoff! site! of! the! superior! labial!artery!was!identified!7.4!mm!laterally!and!5.1!mm!above!a!line!parallel!to!the! lower! edge! of! the! jaw,! between! the! gonion! and! pogonion.! ! Using! inferential! statistics! to! determine! the! branchingOoff! site! of! the! superior! labial! artery! in! the! general!population!from!our!sample,!with!a!95%!confidence!interval,!!we!predicted! the!point!of!emergence!of!the!upper!labial!artery!within!an!area!of!3!sq!cm!in!the! general!population.!!With!tolerance!limits!of!±!9.98!!and!±!7.60!(Table!03)!
The!inferior!labial!artery!was!present!bilaterally!in!eight!of!ten!heads.!In!the!other! two! cases! the! inferior! labial! artery! was! absent! and! the! sublabial! artery! was! identified.!The!mean!point!of!emergence!of!the!inferior!labial!artery!was!24.19!mm! lateral!to!the!oral!commissure!and!9.60!mm!above!the!lower!edge!of!the!jaw,!on!a! line!from!the!gonion!to!the!pogonion.!Using!inferential!statistics!to!determine!the! branchingOoff!site!of!the!inferior!labial!artery!in!the!general!population!from!our! sample,! with! a! 95%! confidence! interval,! we! obtained! two! statistical! tolerance! limits! of! 5! cm! in! the! horizontal! dimension! (±! 24.63)! and! 3! cm! in! the! vertical! dimension!!(±!15.04)!and!(Table!03)!
38! ! ! !
Table!03.!Statistical!analysis!of!measurements! relative!to!point!guides! ! !! !! !! &95%& Nº&of&& Mean& TolerW SD& 95%&Confidence& Artery& Surface&Landmark& Dissec Value& ance& (mm)& interval&p<0.05& Wtions& (mm)& limits& p<0.05& Superior!! Oral!Commissure! Lateral! 20! 7.40! ±!3.63! ±!1.70! ±!9.98! labial!artery! Oral!Commissure*! Superior! 20! 5.12! ±!2.76! ±!1.29! ±!7.60! ! ! ! ! ! ! ! ! Inferior!! Oral!Commissure! Lateral! 20! 24.19! ±!8.95! ±!4.19! ±!24.63! !labial!artery! Base!of!jaw! Superior! 20! 9.60! ±!5.46! ±!2.56! ±!15.04! *&A&line¶llel&to&the&base&of&the&jaw&is&used& SD:&Standard&&Deviation& & !
In!the!mucosal!perforasomes!group!comprised!by!twenty!hemifaces!we!assessed!
the! ! number! of! mucosal! perforators! larger! than! 0,5! mm.! ! We! quantify! their!
diameter,!and!we!perfuse!each!one!of!them!with!diluted!ink!and!determined!the!
perfused! area! by! colouring.! SeventyOfour! perforators! were! measured.! The! mean!
diameter! of! the! perforators! at! the! branchingOoff! site! from! the! facial! artery! was!
0.53±! 0.19! mm.! The! 74! perforators! were! perfused! and! the! mean! area! per!
perforator! was! 279.72±! 156.24! sq.! mm.! We! stress! that! the! perforators! were!
measured!from!the!branchingOoff!site!from!the!superior!labial!artery!and!that!only!
the!ones!larger!than!0.5mm!were!selected.!(Table!04)!
The!first!two!perforators!were!found!in!all!cases,!i.e.!in!all!twenty!hemifaces.!The!
first!perforator!was!found!at!a!mean!distance!of!4.51!±!2.90!mm!,!and!the!second!
perforator!at!a!mean!of!10.34!±!4.19!mm.!In!sixteen!cases!a!third!perforator!was!
found!at!a!mean!of!16.65!±!4.01mm,!in!11!cases!a!fourth!at!a!mean!of!23.10!±!5.23!
mm,!in!six!cases!a!fifth!at!31.74!±!5.31!mm!and!in!only!one!case!a!sixth!at!40.92!
mm.!
!
!
! ! 39! !
!
!
Table!04.!Analysis!of!mucosal!perforators!in!order!of!appearance.!*! ! FAP FAPM!origin! M! Diameter! Coloured!skin! N! over!the!course! Anatomical!localization! PosiO (mm)! surface!(mm2)! of!FA!(mm)! tion! 1st! 20! 4.51!±!2.90! 0.52!±!0.20! 45.00%! AnteroOsuperior! 90%! Anterior!zones! 379.23!±!182.55! ! ! ! ! 45.00%! AnteroOmedial! ! ! ! ! ! ! ! 10.00%! Middle!superior! 10%! Middle!zone! ! 2nd! 20! 10.34!±!4.19! 0.55!±!0.21! 35.00%! AnteroOmedial! 65%! Anterior!zones! 305.83!±!161.84! ! ! ! ! 30.00%! AnteroOinferior! ! ! ! ! ! ! ! 20.00%! Middle!superior! 30%! Middle!zones! ! ! ! ! ! 10.00%! Middle!inferior! ! ! ! ! ! ! ! 5.00%! Posterior! ! ! ! 3rd! 16! 16.65!±!4.01! 0.52!±!0.19! 25.00%! AnteroOinferior! 25%! Anterior!zones! 187.02!±!73.25! ! ! ! ! 50.00%! Middle!superior! 69%! Middle!zones! ! ! ! ! ! 18.80%! Middle!inferior! ! ! ! ! ! ! ! 6.30%! Posterior! 6%! Posterior!zone! ! 4th! 11! 23.10!±!5.23! 0.49!±!0.15! 36.40%! Middle!superior! 82%! Middle!zones! 235.05!±!99.77! ! ! ! ! 45.50%! Middle!inferior! ! ! ! ! ! ! ! 18.20%! Posterior! 18%! Posterior!zone! ! 5th! 6! 31.74!±!5.31! 0.49!±!0.13! 50.00%! Middle!inferior! ! ! 211.12!±!105.58! ! ! ! ! 50.00%! Posterior! ! ! ! 6th! 1! 40.92! ! 100.00%! Posterior! ! ! 153.36! ! ! !! ! !! !! !! !! ! Total& 74! 0.53!±!0.19! 279.72!±!156.24! & FAPM,&facial&artery&perforators&of&the&oral&mucosa;&FA,&facial&artery.& *&Measurement&starting&from&the&bifurcation&of&the&superior&labial&artery.&Results&are&expressed&in& millimetres&as&the&mean&±&standard&deviation.& !
The! perfused! areas! in! the! oral! mucosa! were! classified! in! six! main! types:! three! anterior! areas! near! the! oral! commissure! and! the! lips! (superior,! media! and! inferior),! two! medial! areas! (superior! and! inferior)! and! one! near! the! molars.!
(Figure!13)!
!The! first! and! second! perforators! perfused! in! most! cases! the! anterior! zone! perforasomes! (90%! and! 65%! respectively),! whereas! the! third! and! fourth! perforators!perfused!the!middle!zone!perforasomes!(69%!and!82!%!respectively).!
The!posterior!perforasome!had!various!origins.!(Tables!04!and!05)!!
40! ! ! !
!
FIGURE 13&
Diagram*of*the*oral*mucosal*perforasomes.*The*anterior*area*is*divided*into*three*areas*and* the*medial*area*into*two;*the*posterior*area*is*not*divided.**The*total*area*of*perfused*oral* mucosa*is*between*the*canines*and*a*point*halfway*along*a*line*linking*the*two*points*of* attachment*of*the*second*and*the*third*molar.&
* ! ! ! ! ! ! FIGURE 14
We*can*see*2* mucosal*perE forasomes* colored*with* blue*ink*and* yellow*ink.! !
!
!
! ! 41! !
Table 05. Distribution of oral mucosal perforasomes.The ordinal number is assigned as the mucosal layer was colored.
PERFORASOMES Perfo- Dissection antero antero antero middle middle rators posterior N superior medial inferior superior inferior N
01 2! !! 1! !! !! 2! !! 02 2! !! !! !! 1! !! 2! 03 2! !! !! !! 1! 2! !! 04 5! 1! 2! 3! 4! 5! !! 05 6! 1! 2! 3! 4! 5! 6! 06 5! 1! 2! !! 3! 4! 5! 07 5! !! 1! 2! 3! 4! 5! 08 3! !! 1! !! 2! 3! !! 09 3! !! 1! 2! !! 3! !! 10 3! !! 1! 2! 3! !! !! 11 5! !! 1! 2! 3! 4! 5! 12 3! !! 1! !! 2! 3! !! 13 3! 1! !! !! 2! !! 3! 14 4! 1! !! 2! 3! 4! !! 15 4! !! 1! 2! 3! !! 4! 16 4! 1! 2! !! 3! !! 4! 17 4! 1! 2! 3! !! 4! !! 18 5! 1! 2! 3! 4! 5! !! 19 4! 1! 2! !! 3! 4! !! 20 2! !! 1! !! 2! !! !! ! ! ! ! ! ! TOTAL 74 9 16 10 17 14 8 !! !! !! !! !! !! !! !! !
The!stained!area!corresponded!to!a!triangle!of!oral!mucosa!located!between!the! canines!and!a!point!halfway!along!a!line!between!the!second!and!third!upper!and! lower!molars.!(Figure!14!and!15)!.!!
42! ! ! !
!
FIGURE 15&
Five*stained*areas.*They*correspond*with*the*anterior*zones:*anteroEsuperior*(yellow),* anteroEmedial*(blue)*and*anteroEinferior*(red),*and*with*the*middle*zones:*middleEsuperior* (white)*and*middleEinferior*(black).*The*total*stained*area*represents*the*area*perfused*by* the*mucosal*perforators*from*the*facial*artery.* !
FLAP HARVESTING
The!proximal!flaps!of!the!facial!artery!had!an!arc!of!rotation!covering!as!far!as!the! mid!line!of!the!lower!lip,!the!oral!commissure,!and!the!posterior!third!of!the!palate.!
(Figures! 16O18)! The! reversalOflow! flaps! reached! the! upper! lip,! the! two! anterior! thirds! of! the! palate,! the! nasal! septum! and! the! superior! palpebral! conjunctiva.!
(Figures!19O21)!!!
! ! 43! !
!
FIGURE 16&
Proximal*oral*mucosal*flap*for*reconstruction*of*the*oral*commissure.*The*total*area*is* shrunk*by*the*elasticity*properties*of*the*mucosa.** ! !
!
FIGURE 17&
Proximal*oral*mucosal*flap*for*reconstruction*of*the*lower*lip.*
44! ! ! !
!
FIGURE 18&
Proximal*oral* mucosal*flap*for* reconstruction*of* the*posterior* third*of*the* palate.*Note*the* pedicle*over*the* lightEblue*insert.* ! ! ! ! ! ! ! ! ! ! ! ! !
FIGURE 19&
Reverse*flow*oral*mucosal* flap*for*reconstruction*of*the* two*anterior*thirds*of*the* palate.*We*can*see*the* mucosal*flap*based*on* mucosal*perforators*stained* with*yellow*and*blue.**
* ! !
! ! 45! !
!
FIGURE 20&
Reverse*flow*oral* mucosal*flap*for* reconstruction*of*the* nasal*septum.*In*this* specimen*we*open*the* nasal*alae*to*position* our*flap*and*provide* clear*exposure.*The* pedicle*is*over*the*blue* insert.* ! ! !
!
FIGURE 21&
Reverse*flow*oral*mucosal*flap*for*reconstruction*of*the*palpebral*inferior*conjunctiva.*We* make*an*incision*next*to*the*nasal*ala*to*expose*the*pedicle.! !
46! ! ! !
STATISTICAL ANALYSIS
MUCOSAL PERFORATOR GROUP
A!statistically!significant!inverse!correlation!was!found!between!the!position!of!the! mucosal!perforator!over!the!facial!artery!from!the!lower!edge!of!the!jaw!and!the! length!of!the!perforator!(p!<0.05).!(Figure!22)!
!
FIGURE 22&
Relation*between*the*position*of*the*mucosal*perforator*over*the*facial*artery*(FA)*from*the* lower*edge*of*the*jaw*and*the*length*of*mucosa*perforator.*(p<0.05)*
& !
No!significant!correlations!were!found!between!the!diameter!of!the!facial!artery! and! its! total! length! or! the! number! of! perforators.! Nor! were! there! statistically! significant! correlations! between! the! length! and! the! diameter! of! the! mucosal! perforators,!or!between!the!position!of!the!perforator!over!the!facial!artery!and!the! perforator’s!diameter.!
! ! 47! !
MUCOSAL PERFORASOMES GROUP
There!was!a!statistically!significant!correlation!between!the!diameter!of!the!artery! at!the!base!of!the!jaw!and!at!its!branchingOoff!point!from!the!superior!labial!artery!
(p<0.05).!(Figure!23)!
!
FIGURE 23&
Relation*between*the*diameter*of*the*facial*artery*(FA)*at*the*base*of*the*mandible*and*its* diameter*at*the*exit*of*the*superior*labial*artery*(SLA).* !
The! Spearman's! rank! correlation! coefficient! showed! a! significant! inverse! correlation!between!the!distance!from!the!exit!point!of!the!perforators!starting!at! the! branchingOoff! point! of! the! superior! facial! artery! and! the! stained! areas! of! the! oral!mucosa!(p<0.001).!(Figure!24)!
48! ! ! !
!
FIGURE 24&
Relation*between*the*mucosal*oral*perforators*of*the*facial*artery*over*the*facial*artery*(FA)* and*the*perfusion*areas*in*the*mucosa*measured*in*mm2.*(p<0.001).* !
No! statistically! significant! correlations! were! found! between! the! facial! artery! diameter!and!its!length!until!the!superior!labial!artery.!Nor!was!there!a!statistical! correlation! between! artery! diameters! measured! at! the! three! points! described! above!and!the!length!of!the!artery,!nor!between!these!diameters!and!the!number!of! perforators!larger!than!0.5!mm,!nor!between!the!diameter!of!the!perforators!and! the!perfused!areas.!
DEFINITION OF THE TERM MUCOSAL PERFORASOMES.
In! the! Pubmed! search! on! the! 24th! September! 2015,! the! key! words! "mucosa! perforator"! yielded! twentyOthree! articles.! We! found! fifteen! articles! using! "oral! mucosa! perforator",! seventeen! articles! using! "oral! mucosa! perforator",! and! nineteen! articles! using! “oral! mucosal! perforator”.! The! key! words! "oral! mucosa!
! ! 49! ! perforator!flap"!and!"oral!mucosal!perforator!flap"!yielded!seventeen!and!fifteen! articles!respectively.!!
From!nineteen!articles!of!bibliographical!data!two!articles!were!excluded!because! they!are!our!own!descriptions!and!include!our!definitions.!Seventeen!articles!were! identified! (8O24).! ! Fifteen! described! the! reconstruction! of! the! oral! area! with! cutaneous!perforator!flaps!from!other!areas!of!the!body.!The!other!two!described! the! reconstruction! of! the! oral! mucosa! with! local! flaps.! They! did! not! mention! mucosal!perforators!or!perforasomes.!
With!the!key!words!"perforasome"!and!"perforasomes"!each!yielded!nine!articles,! before!14th!June!2013.!On!24th!September!2015!the!word!“perforasome”!returned! sixteen!results,!and!the!word!“perforasomes”!generated!thirteen!sources.!Two!of! them! refer! to! our! articles.! In! all,! sixteen! articles! were! identified! (25O40).! There! were! no! references! to! mucosal! perforasomes.! None! of! the! references! quoted! in! these!articles!mentioned!mucosal!perforators!or!their!perforasomes!except!for!our! own!work.!
The! search! in! the! Cochrane! Library! with! the! terms! "mouth! mucosa"! and! "flap! perforators"! did! not! find! any! results.! None! of! the! articles! referred! to! the! perforating! arteries! of! the! mucosa,! to! the! areas! perfused,! or! to! mucosal! perforasomes.!
!
CLINICAL USE IN SEPTAL PERFORATION SECONDARY TO
COCAINE ABUSE.
We!saw!five!cases!with!septal!perforations!due!to!cocaine!use.!(Table!06).!
50! ! ! !
Table!06.!General!description!of!the!patients.! ! Defect& Abstention&Time& FollowWup& ! N& ! Sex& !Age& ! ! ! ! Procedures& (mm)& (months)& (months)& 1! Female! 22! 20!x!16! 6! 22! MPBF! 2! Female! 25! 22!x!15! 12! 14! MPBF,!PAF,!cartilage!graft! 3! Female! 28! 25!x!12! 30! 15! MPBF,!open!rhinoplasty! 4! Male! 36! 31!x!23! 20! 18! MPBF! 5! Female! 40! 22!!x!12! 24! 34! MPBF! Mean! !! 30.2! 24!x!15.6! 18.4! 20.6! !! MPBF:&Mucosal&Perforasomes&Based&Flap;&PAF:&Palatine&Artery&Flap,&mm:&millimeters& !
Mean! age! was! 30.2! years.! Four! were! female! and! one! male! (Figures! 25! and! 26).!
They!reported!quitting!their!cocaine!habit!on!average!18!months!previously.!The! mean!septal!perforation!was!24!x!15.6!mm.!Patients!were!followed!for!a!mean!of!
20.6!months!(range!15O34!months).!(Figure!25)!
!
! ! ! ! ! ! FIGURE 25 !
Clinical*case*with*a*complex*defect*in*the*hard* palate*and*the*nasal*septum..* !
! ! ! !
FIGURE 26
Satisfactory*evolution*of*the*former*patient.**
We*use*a*palatine*axial*flap*to*close*the*palate* and*a*mucosalEbased*perforator*flap*(MPBF)*to* reconstruct*the*nasal*septum,*both*performed* in*the*same*surgical*procedure*
! ! 51! !
!
FIGURE 27&
Preoperative*views*on*top*and*bottom*left*.*PostEoperative*views*on*top*and*bottom*right*at* 10*months*followEup,*demonstrating*improvement*in*the*nasal*shape*and*correction*of*the* palatal*defect.*Restoration&of&the&defect&and&nose&reconstruction&was&achieved.& ! !
52! ! ! !
DISCUSSION
MUCOSAL PERFORATORS AND MUCOSAL PERFORASOMES
Admittedly,! surgeons! need! to! base! their! surgical! practice! upon! accurate! anatomical! knowledge.! But! what! happens! when! our! anatomical! knowledge! is! erroneous!?!!For!many!centuries!our!knowledge!about!the!anatomy!of!the!human! vessels! was! based! on! erroneous! ideas.! Even! Galen! made! some! mistakes! in! describing!the!pulmonary!circulation!and!the!errors!remained!for!centuries,!until! other!anatomists,!such!as!Michael!Servetus!and!Ibn!alONafis,!refuted!his!ideas!(32).!
Later! on,! some! misconceptions! were! refuted! by! Harvey! in! his! book( Exercitatio(
Anatomica( de( Motu( Cordis( et( Sanguinis( in( Animalibus! (33).! In! this! book! “Harvey! frequently! explains! experimental! procedures! in! a! way! that! invites! the! reader! to! reconstruct! them! in! his! mind! or! perhaps! to! perform! them,”! as! Jole! Shackelford! explains,!in!a!book!about!the!history!of!William!Harvey!!(34).!
A! thorough! knowledge! of! vascular! anatomy! is! crucial! to! the! understanding! and! performance!of!any!kind!of!surgical!act!and!especially!so!in!perforator!flap!surgery.!
Many!studies!on!this!subject!have!been!published!recently.!(35O38)!The!perforator! flaps!allow!primary!closure!of!some!defects!and,!more!importantly,!the!use!of!the! reconstructive!principle!of!replacing!“like!with!like”!tissues.!!
To!date,!the!study!of!facial!perforators!has!focused!on!those!that!terminate!in!the! skin.!(8)!This!study!demonstrates!that!there!are!also!perforators!that!terminate!in! the!oral!mucosa.!These!perforators!are!slightly!narrower!and!shorter!than!those!in! the!facial!skin.!(8,18,39).!
! ! 53! !
The!concept!of!“mucosal!perforator!flap”!does!not!exist.!!Moreover!the!concept!of!a! perforator! flap! is! not! standardized:! at! present,! the! only! variables! included! in! all! definitions!are!the!skin!and/or!the!subcutaneous!tissue.!Sinna!(9)!states!“It!is!clear! from!the!international!literature!that!various!authors!have!failed!to!agree!on!what! qualifies!as!a!perforator!flap.”!!The!Gent!Consensus(10)!in!its!introduction,!affirms!! that!“because!the!area!of!perforator!flaps!is!new!and!rapidly!evolving,!there!are!no! definitions! and! standard! rules! on! terminology! and! nomenclature,! which! creates! confusion!when!surgeons!try!to!communicate!and!compare!surgical!techniques.”!
Wei!(11)!express!concern!about!what!is!a!true!perforator!flap!.Giunta!and!Hallock!
(12O13)!manifest!the!same!doubts.!!
The! latex! injection! technique! remains! useful! for! identifying! the! territories! perfused!by!an!artery.!Bergeron!in!a!review,!underlines!the!importance!of!latex!in! the! dissection! process! but! makes! known! that! “latex! only! allows! visualization! of! blood! vessels! and! does! not! allow! gross! visual! assessment! of! the! skin! territory! perfused! by! a! given! vessel”(40,! 41)!!!To! overcome! that! handicap! we! diluted! the! latex!in!order!to!reach!the!small!perforators,!but!it!remained!excessively!dense!and! was! unable! to! perfuse! the! more! distal! areas! in! the! mucosal! plexus.! As! a! consequence,! we! designed! another! protocol! with! diluted! ink! to! obtain! proper! results!in!that!part!of!the!study.!!
In! clinical! cases! with! living! patients! the! possibility! of! using! color! Doppler! techniques!to!define!the!course!of!the!facial!artery!has!already!been!proposed.(42)!
CT!allows!better!characterization!of!the!facial!artery!(43)!but!these!techniques!are! of!little!use!in!vessels!with!a!caliber!of!less!than!1!mm.!(44)!Therefore!in!our!study! we! tried! to! define! a! landmark! useful! for! this! kind! of! vessels.! In! our! study! we!
54! ! ! ! determined! the! emergence! of! the! mucosal! perforators! of! the! facial! artery! by! injection!with!latex!and!determined!their!relative!position!in!relation!to!the!other! elements!near!the!region.!!!We!observed!the!majority!of!perforators!between!the! branchingOoff! site! of! the! superior! labial! artery! and! the! inferior! labial! artery! or! sublabial!artery!in!the!case!of!the!abscense!of!the!inferior!labial!artery.!This!data! suggests! a! guide! point! based! on! the! emergence! of! the! labial! arteries! for! the! localization!of!mucosal!perforators!from!the!facial!artery.!
In!all!cases,!the!superior!labial!artery!branched!off!bilaterally!from!the!facial!artery.!
Our! data! corroborate! those! of! most! other! reports;! (45,46)! they! diverge! slightly! from! those! described! by! Magden! (47),! probably! because! those! authors! used! preserved! formalin! cadavers! rather! than! fresh! frozen! heads.! When! formalin! is! used!for!tissue!processing,!the!most!important!problem!is!inadequate!tissue! dehydration!(69)!!and!that!is!reflected!in!the!shrinkage!of!the!specimen.!!
Using! inferential! statistics! we! were! able! to! predict! the! branchingOoff! site! of! the! labial!superior!artery!in!an!area!2!cm!long!and!1.5!cm!high!with!a!surface!area!of!3! sq!cm!for!95%!of!the!general!population.!This!method!was!reported!by!Whetzel!
(48)!for!the!description!of!certain!perforators!of!the!facial!region.!
We!do!not!advise!the!use!of!the!inferior!labial!artery!as!a!guide!point!because,!in! spite!of!the!fact!that!in!the!majority!of!cases!it!was!present!bilaterally,!in!two!cases! it! was! not! identified.! This! is! consistent! with! the! great! variability! of! the! artery! described! by! Edizer.! (49)! The! branchingOoff! site! of! the! inferior! labial! artery! was! less! predictable:! statistically,! the! tolerance! limits! for! determining! an! area! with!
95%!confidence!for!individuals!in!a!population!were!3!cm!in!height!and!5!cm!in! length,!i.e.!the!branchingOoff!site!could!be!in!an!area!of!around!15!sq.!cm.!
! ! 55! !
The! perfused! areas! matched! with! the! number! of! mucosal! perforators! selected.!
After!studying!the!74!stained!territories!in!all!the!cadavers,!it!was!clear!that!the! perfusion! was! different! in! each! cheek,! and! even! in! the! same! corpse.! They! were! most!consistently!found!in!the!anterior!areas;!the!first!pair!of!perforators!perfused! mainly!the!anterior!perforasomes!and!the!next!two!the!medial!perforasomes.!This! may!be!because,!in!the!light!of!previous!descriptions,!it!was!decided!to!select!only! mucosal!perforators!larger!than!0.5!mm.!(8,18)!!
The!mean!area!perfused!by!each!perforator!was!279.72!!sq.!mm.,!which!is!notably! lower!than!the!cutaneous!territories.!The!six!areas!of!perfusion!were!similar!to!the! pattern!described!in!the!skin!(8)!and!are!compatible!with!SaintOCyr’s!perforasome! theory.!(50)!The!posterior!perforasome!probably!shares!perfusion!with!the!buccal! artery!or!the!anastomosis!between!the!buccal!and!facial!artery!described!by!Zhao.!
(16)!This!could!explain!the!diverse!sources!of!perfusion!for!the!posterior!territory.!
In!those!cases!where!only!two!or!three!perforators!larger!than!0.5!mm!were!found,! the!total!stained!area!invariably!reproduced!the!triangleOshaped!zone!between!the! canines!and!a!point!halfway!along!a!line!between!the!second!and!third!upper!and! lower! molars.! All! of! the! cheek! mucosa! inside! that! triangle! could! probably! be! elevated!as!a!flap!on!these!two!or!three!perforators.!The!blood!supply!to!the!whole! mucosa!triangle!would!be!provided!by!the!direct!and!indirect!linking!vessels,!as! described!for!other!perforator!flaps.!(51,52)!
In! agreement! with! Qassemyar,! we! did! not! find! any! statistically! significant! correlation!between!the!diameter!of!mucosal!perforators!and!the!perfused!areas.!
In! the! same! way,! we! found! a! statistically! significant! inverse! correlation! between! the! origin! of! the! perforator! and! the! perfused! area.! Also! we! found! a! statistically!
56! ! ! ! significant! correlation! between! the! origin! of! the! mucosal! perforator! above! the! facial! artery! and! the! length! of! the! mucosal! perforator.! That! is,! the! perforators! nearest!the!branchingOoff!site!of!the!superior!labial!artery!were!shorter!than!the! perforators! next! to! the! base! of! the! mandible.! This! finding! is! relevant! to! the! selection!of!the!proximal!perforators!when!a!longer!pedicle!is!needed.!
Whetzel!(53)!proposed!that!the!primary!arterial!supply!to!the!oral!mucosa!of!the! cheek!was!provided!by!the!buccal!and!labial!arteries.!Our!data!demonstrate!that! the!mucosal!perfusion!of!the!cheek!is!done!with!perforators!from!the!facial!artery! after! the! branchingOoff! point! from! the! inferior! labial! artery! and! before! the! exit! point! of! the! superior! labial! artery,! since! the! labial! arteries! had! been! previously! ligated!to!exclude!their!arterial!supply!to!the!mucosa!of!the!cheek.!!Therefore,!we! should! not! dissect! beyond! the! superior! labial! artery! or! the! inferior! labial! artery!
(depending! on! our! flap! design)! when! we! want! to! ensure! the! perfusion! of! a! flap! based! on! the! facial! artery! perforators! for! the! mucosa! of! the! cheek.! ! The! labial! arteries!provide!similar!perforators!for!the!labial!mucosa,!so!that!we!can!harvest! more!mucosa!when!we!need!more!oral!mucosa!for!some!reconstruction.!
!
Pribaz!(14,!54)!describes!the!FAMM!flap!for!the!reconstruction!of!the!oral!mucosa! based!on!the!facial!artery.!However,!the!maximum!amount!of!mucosa!that!can!be! harvested!has!not!been!described.!Landes!et!al.!(15)!have!described!the!dorsallyO pedicled! buccal! musculoOmucosal! (DPBM)! flap! and! have! stated! that! this! flap! is! supported!by!the!submucosal!plexus!and,!for!that!reason,!a!thin!layer!of!buccinator! is!included!to!preserve!that!plexus.!We!could!assume!that!the!plexus!is!eventually! supported!by!the!musculoOmucosal!perforators!from!the!facial!artery.!Matros!(55)!
! ! 57! ! reports! a! technique! for! placing! the! pedicle! in! patients! with! intact! dentition! and! avoiding!twoOstage!reconstruction.!Zhao(16)!describes!the!buccinator!myomucosal! island! flap! for! harvesting! mucosa! from! the! same! zone! to! perform! diverse! reconstructions! of! the! oral! cavity! and! beyond.! However,! they! did! not! describe! either!the!oral!mucosal!perforators!of!the!facial!artery!or!the!areas!they!perfuse.!
Here! we! describe! the! maximum! amount! of! mucosa! that! can! be! harvested! to! perform!a!reconstruction,!reflected!by!the!perfusion!of!the!cheek!mucosa!by!the! perforators!deriving!from!the!facial!artery.!!
We!have!reported!on!a!map!of!the!six!areas!perfused!by!the!mucosal!perforators!of! the! facial! artery.! The! most! reliable! are! the! anterior! and! medial! areas.! The! total! stained!area!of!oral!mucosa!perfused!by!the!perforasomes!from!the!facial!artery! describes! a! triangularOshaped! area! that! could! be! selected! to! design! madeOtoO measure!flaps.&
Our! study! demonstrates! that! it! is! possible! to! make! flaps! based! on! the! mucosal! perforators! from! the! facial! artery,! and! our! data! may! also! help! to! improve! the! harvesting!of!flaps!based!on!the!facial!artery.&
DEFINITION OF NEW TERMS
In!view!of!the!absence!of!references!in!the!literature,!we!propose!the!concept!of! the!"mucosal!perforasome",!a!unique!vascular!territory!perfused!by!a!perforator! artery! in! the! mucosa.! This! concept! may! be! useful! because! it! allows! a! clearer! understanding!of!the!blood!supply!of!the!areas!of!mucosa!in!general;!it!can!guide! the!creation!of!flaps!of!this!kind!and!can!differentiate!them!clearly!from!perforator! flaps!described!in!the!skin.!!
58! ! ! !
To! our! knowledge,! there! are! no! descriptions! in! medical! literature! of! “mucosal! perforator”.!We!believe!the!determination!of!this!concept!may!be!useful,!because!it! allows! a! clearer! understanding! of! the! blood! supply! of! the! areas! of! mucosa! in! general.!
This! information! should! be! valuable! in! the! harvesting! of! any! flap! based! on! the! mucosal!perforators!of!the!facial!artery,!and!in!improving!the!making!of!currently! used! flaps.! Our! interest! is! specially! aimed! towards! the! reconstruction! of! nasal! septal!defects!caused!by!inhalation!of!cocaine.!!
CLINICAL USE IN SEPTAL PERFORATION SECONDARY TO
COCAINE ABUSE.
Many! types! of! local! flap! have! been! described! for! reconstruction! of! the! nasal! septum!(66,67),!including!oral!mucosa!flaps!based!on!the!vascular!network!from! the!deep!ascendant!branches!of!the!labial!artery!and!orbicular!muscle.!However,! they!only!cover!small!periorificial!defects!(68).!
Regional!flaps!are!an!option!amongst!others:!Pribaz!with!the!FAMM!(14)!and!Zhao! with!the!the!buccinator!island!flap.!(16)!With!our!descriptions!we!can!select!the! areas!with!the!best!vascularization!corresponding!to!the!anterior!perforasomes!of! the!oral!mucosa,!which!are!perfused!by!the!mucosal!perforators!of!the!facial!artery.!
These!wellOvascularized!areas!are!optimal!for!the!reconstruction!of!a!septal!defect,! because! they! comprise! mucosa,! the! flap! is! relatively! thin,! and! their! perfusion! is! well!determined;!they!are!especially!useful!in!situations!where!the!vascularity!of! the!area!has!been!chronically!damaged,!as!in!septal!perforation!due!to!cocaine!use.!
This! procedure! guarantees! an! excellent! result,! always! provided! that! the! patient!
! ! 59! ! gives! up! his/her! cocaine! habit.! With! the! description! of! those! areas! or! “mucosal! perforasomes”! we! could! harvest! those! optimal! wellOvascularized! territories! for! reconstructing!a!septal!defect,!and/or!another!defect!in!the!oroOnasal!region.!
OTHER POSSIBLE CLINICAL USES
Our!findings!may!stimulate!the!search!for!similar!mucosal!areas!elsewhere!in!the! body.! The! observation! of! specific! areas! in! the! mouth! may! be! replicated! in! other! sites!where!reconstruction!of!the!mucosa!lining!is!needed,!following!the!principle! of!"like!with!like!tissue".!This!may!well!improve!the!quality!of!the!reconstructions! and!reduce!the!need!for!harvesting!of!distant!tissues.!
These!flaps!have!smaller!caliber!perforators!than!their!counterparts!in!the!skin,!at! least!in!the!area!of!the!mouth.!It!remains!to!be!determined!whether!in!other!areas! of! the! body! the! same! configuration! exists,! or! possibly! even! one! that! is! more! favorable! from! the! surgical! viewpoint.! The! identification! of! these! areas! may! be! extremely! useful! in! the! reconstruction! of! intestinal,! genitourinary,! and! genital! mucosa.!
60! ! ! !
CONCLUSIONS
1. The!oral!mucosa!of!the!cheek!has!direct!perforators!arising!from!the!facial!
artery.!
2. The!majority!of!the!facial!artery!perforators!for!the!oral!mucosa!of!the!
cheek,!are!located!between!the!branchingOoff!point!of!the!superior!and!
inferior!labial!artery.!
3. The!oral!mucosa!presents!wellOdefined!territories,!each!mainly!perfused!by!
a! single! perforator,! which! we! term! "mucosal! perforasomes".! Here! we!
present!a!definition!of!the!term.!!
4. We!describe!a!map!of!the!six!areas!perfused!by!the!mucosal!perforators!of!
the!FA.!The!most!reliable!are!the!anterior!and!medial!areas.!
5. The!total!stained!area!of!oral!mucosa!perfused!by!the!perforasomes!from!
the!FA!describes!a!triangularOshaped!area!that!could!be!selected!to!design!
madeOtoOmeasure!flaps.!!
6. Our!identification!of!mucosal!perforators!deriving!from!the!facial!artery!has!
allowed! us! to! design! a! wellOvascularized! flap! for! the! reconstruction! of!
defects! in! the! nasal! septum.! We! believe! that! this! flap! is! very! useful!
especially! in! situations! where! the! vascularity! of! the! area! has! been!
chronically!damaged.!
7. We!think!that!our!findings!shed!new!light!on!the!perfusion!of!mucosas!and!
may! be! applicable! to! other! areas! of! the! body.! They! may! also! have!
implications!for!the!use!of!mucosal!flaps!in!reconstructive!surgery.!!
8. Our!findings!have!been!used!to!support!new!advances!in!the!field!of!oral!
reconstruction.!(70).!
! ! 61! !
62! ! ! !
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!
66! ! ! !
DEDICATION AND ACKNOWLEDGEMENTS
! To!Jesus!Christ!my!Savior!and!Redeemer.! To!all!my!family!here!and!in!the!heavens.!
! ! !
I! should! like! to! express! my! appreciation! to! my! tutors! .! First! to! Prof.! José! María!
SerraO!Renom!for!all!his!time!and!dedication!in!the!checking!of!this!project!and!for! guiding! me! in! the! process! of! producing! scientific! papers,! for! providing! me! with! support! when! we! had! to! deal! with! our! reviewers! all! over! the! world,! for! giving! feedback! on! all! the! doubts! that! emerged! on! this! work,! and! for! the! surgical! and! clinical!!mentoring!on!my!specialization.!!
! To!Marian!Lorente!for!the!provision!and!preservation!of!the!material!for!this!work.!
To!!Anne!Silva!,!for!all!the!time!spent!in!the!correction!of!our!drafts!in!order!to! obtain!a!legible!work,!and!for!her!suggestions!in!order!to!make!this!scientific!work! available!to!all.!
!
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ARTICLES
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70! ! !
YBJOM-4224; No. of Pages 4 ARTICLE IN PRESS
Available online at www.sciencedirect.com
British Journal of Oral and Maxillofacial Surgery xxx (2014) xxx–xxx
Mucosal perforators from the facial artery
a,b, a,b c,b
Mauricio E. Coronel-Banda ∗, Jose M. Serra-Renom , Marian Lorente ,
d
Wendy P. Larrea-Terán
a
Institute of Aesthetic and Plastic Surgery Dr. Serra-Renom, Hospital Quirón Barcelona, Plaza Alfonso Comín, 5-7, 08023 Barcelona, Spain
b
Universitat Internacional de Catalunya, Spain
c
Laboratory of Functional and Surgical Anatomy, Campus Sant Cugat, Josep Trueta S/N, 08195 Sant Cugat del Vallès, Spain
d
Milenium Coru˜na Medical Center, C / Federico Tapia 45, 15008 A Coru˜na, Spain
Accepted 16 March 2014
Abstract
The cutaneous perforators of the facial artery have been well described, but to our knowledge the oral mucosal perforators have not. We
studied 10 facial arteries from 10 hemifaces in 5 cadavers. The arteries were injected with latex, and we studied all perforators that extended
from the facial artery and headed directly to the oral mucosa. The diameter and length of the facial artery and its mucosal perforators were
measured and compared. We found 52 oral mucosal perforators in the 10 facial arteries injected with latex. Their mean (SD) diameter was 0.5
(0.2) mm and the mean (SD) number/facial artery was 5.2 (1.1). Their mean (SD) length was 16.4 (5.3) mm. Most of those to the cheek were
localised between the branching-off points of the inferior and superior labial arteries. The facial artery has perforators to the oral mucosa of
the cheek, most of them between the points at which the labial arteries emerge.
© 2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Keywords: Facial artery; Mucosal perforators; Oral mucosa
Introduction description of facial artery perforator flaps by Hofer et al.
5
was limited to perforators that lead to the skin.
The reconstruction of the oral mucosa is an area of inter- The objective of this study was to identify the facial artery
est to facial surgeons. Techniques have evolved considerably perforators in the oral mucosa of the cheek, and to find out
1
since the introduction of perforator flaps, which have been how many there are, their diameter and length, and their dis-
2–4
described in detail in recent years. The development of tribution in relation to the facial artery. This information is
perforator flaps allows single-stage operations and the use of relevant to the harvesting of flaps based on the mucosal per-
made-to-measure flaps. forators of the facial artery, and to the harvesting of the flaps
Even though we suspect the existence of perforators in the that are already in routine use.
oral mucosa, we need to prove their existence. The classic
Material and methods
∗ Corresponding author at: Institute of Aesthetic and Plastic Surgery Dr.
Five heads of fresh-frozen cadavers were used, with 10
Serra-Renom, Hospital Quirón Barcelona, Plaza Alfonso Comín, 5-7, 08023
hemifaces that were dissected. The perforators in the
Barcelona, Spain. Tel.: +34 93 284 81 89.
E-mail address: [email protected] oral mucosa of the cheek that extended from the facial
(M.E. Coronel-Banda). artery (previously injected with latex) were identified. A
http://dx.doi.org/10.1016/j.bjoms.2014.03.013
0266-4356/© 2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
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2 M.E. Coronel-Banda et al. / British Journal of Oral and Maxillofacial Surgery xxx (2014) xxx–xxx
Descriptive anatomy
The facial artery was identified at its exit point from the
mandibular branch. The dissection proceeded in an antegrade
fashion from the artery to the mucosa up to its anastomosis
with the angular artery. The diameter of the artery was mea-
sured at the base of the jaw. Dissection was continued to
identify and preserve the oral mucosal perforators, and their
origin over the facial artery, taking the base of the jaw as
reference (Fig. 2). The perforators from the upper and lower
labial arteries were not examined.
Measurements
We used the Image J software version 1.45s was used (W.
Fig. 1. Midline incision in the chin, oral mucosa incision, and raising of the
S. Rasband, ImageJ, U.S. National Institutes of Health,
cheek flap. Note the origin of the facial artery at the base of the jaw marked
Bethesda, MD, http://rsb.info.nih.gov/ij). The measurements
with a silk suture.
were made on two photographs taken 30 cm away from the
specimen. After it had obtained the scale and the conver-
submandibular incision was made 2 cm below the lower edge
sion rate, the program converted the measurements into the
of the jaw, and the facial artery and vein were identified at
distances recorded.
the level of their branching-off points below the edge of the jaw.
Statistical analysis
Injection of latex
We used the STATA program version 11.1 (Lakeway Drive,
Texas, USA). To assess the normality of the distribution of the
The arteries were washed out with saline 30 ml, and two
variables we applied the Shapiro Wilk test, and to assess the
incisions made at the nasal philtrum to verify fluid outflow.
normality of the variables we applied the normal probability
Roughly 4 ml of diluted LME/R1 latex (Latex Compound
plot technique. When the distribution of the variables was
Spanish SA Sabadell) was injected, until it was seen to flow
normal, we used the Spearman’s R Correlation test to assess
out through the nasal incisions. The excess was removed and
the significance of differences. When the distribution was not
the samples frozen at 13 ◦C for 24 h.
− normal, the significance was assessed using Spearman’s rank
An incision was made in the midline of the lower lip and
correlation coefficient. Probabilities of less than 0.05 were
chin. A flap was lifted in the oral mucosa at the level of
accepted as significant.
the gingival sulcus that included the periosteum and reached
the sphenomandibular ligament (Fig. 1). The dissection was
submucosal to show the perforators that extended from the
Results
facial artery to perfuse the oral mucosa (Fig. 2).
Details of the measurements are given in Table 1. The distri-
bution of the mucosal perforators from the facial artery shows
that most of them were about 4–8 cm from the base of the jaw
(Fig. 3).
Most of the mucosa of the cheek was reached directly by
perforators from the facial artery. The mucosa of the lips was
reached by perforators from the labial arteries, although these
arteries were not the subject of our study. The superior labial
artery was found in all cases. In two cases, the inferior labial
artery was not found; in both these cases, the sublabial artery
was identified.
Statistical analysis
There was a significant inverse correlation between the posi-
tion of the mucosal perforator over the facial artery from
Fig. 2. Red latex specimen. Exposure of facial artery and the mucosal per-
forators. The mucosal perforators (mp) can be seen between the points at the lower edge of the jaw and the length of the perforator
which the superior and inferior labial arteries emerge (black arrows). (p = 0.028) (Fig. 4).
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M.E. Coronel-Banda et al. / British Journal of Oral and Maxillofacial Surgery xxx (2014) xxx–xxx 3
Table 1
Measurements (diameter and length) of the facial artery and mucosal perforators (mm). Data are mean (SD) unless otherwise stated.
Dissection No. Diameter Total length of facial artery No. of mucosal perforators Diameter Length
1 2.0 122.1 4 0.6 (0.2) 20.3 (2.5)
2 2.6 108.0 6 0.4 (0.1) 18.5 (7.4)
3 2.3 98.9 7 0.5 (0.2) 11.5 (1.5)
4 2.0 105.5 4 0.4 (0.2) 21.7 (3.9)
5 2.5 130.3 5 0.6 (0.1) 20.1 (2.7)
6 2.3 117.5 7 0.5 (0.1) 10.8 (5.0)
7 2.4 134.8 5 0.5 (0.1) 17.6 (1.9)
8 2.8 115.9 4 0.5 (0.1) 14.8 (3.9)
9 2.9 125.7 5 0.6 (0.1) 16.1 (1.8)
10 2.8 134.3 5 0.5 (0.3) 18.2 (6.3)
Mean (SD) 2.5 (0.3) 119.3 (12.4) 5.2 (1.1) 0.5 (0.2) 16.4 (5.3)
Discussion
To date the study of facial perforators has focused on those
5
that terminate in the skin. In this study we have shown that
there are also perforators that terminate in the oral mucosa.
These are slightly lower, narrower, and shorter than their cuta-
6,7
neous counterparts. The latex injection technique remains
8,9
useful for identifying the perforator vessels from an artery.
We diluted the latex so that we could reach the small perfo-
rators from the facial artery.
10
Whetzel and Saunders proposed that the primary arterial
perfusion of the oral mucosa of the cheek was provided by the
buccal and labial arteries. Our data show that the oral mucosa
is also reached by perforators of the facial artery. We found
most of them after the branching-off point from the inferior
labial artery and before the exit point of the superior labial
Fig. 3. Distribution of the mucosal perforators over the facial artery. The
artery. We should not therefore dissect beyond the superior
columns indicate the number of mucosal perforators that we found (n = 52)
labial artery or the inferior labial artery (depending on the
in consecutive segments of 2 cm from the base of the jaw.
design of our flap) when we want to ensure the perfusion of
a flap based on the mucosa of the cheek. The labial arteries
There were no significant correlations between the diame- provide similar perforators for the labial mucosa, and can be
ter and length of the facial artery or the number of perforators, harvested when oral mucosa is needed.
nor were there any significant correlations between the length We found a significant correlation between the origin of
and diameter of the mucosal perforators, or between the posi- the mucosal perforator above the facial artery and the length
tion of the perforator over the facial artery or its diameter. of the mucosal perforator. That is, the perforators nearest the
Fig. 4. Relation between the position of the mucosal perforator over the facial artery (FA) from the lower edge of the jaw and the length of the mucosal
perforator (p = 0.028).
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YBJOM-4224; No. of Pages 4 ARTICLE IN PRESS
4 M.E. Coronel-Banda et al. / British Journal of Oral and Maxillofacial Surgery xxx (2014) xxx–xxx
branching-off site of the superior labial artery were not as 3. Bravo FG, Schwarze HP. Free-style local perforator flaps: concept
and classification system. J Plast Reconstr Aesthet Surg 2009;62:
long as the perforator next to the base of the mandible. This
602–9.
finding is relevant to the selection of the proximal perforators
4. D’Arpa S, Cordova A, Pirrello R, et al. Free style facial artery perforator
when a longer pedicle is needed. In future work it would
flap for one stage reconstruction of the nasal ala. J Plast Reconstr Aesthet
be interesting to find out if this difference affects the areas Surg 2009;62:36–42.
perfused by the mucosal perforators. 5. Hofer SO, Posch NA, Smit X. The facial artery perforator flap
7 for reconstruction of perioral defects. Plast Reconstr Surg 2005;115:
Ng et al. described a reference point from which to find
996–1005.
cutaneous facial artery perforators. The possibility of using
6. Qassemyar Q, Havet E, Sinna R. Vascular basis of the facial artery per-
colour Doppler techniques to find out if the perforators are
forator flap: analysis of 101 perforator territories. Plast Reconstr Surg
2,11,12
from the facial artery has already been proposed. CT 2012;129:421–9.
13
allows characterisation of the facial artery, but these tech- 7. Ng ZY, Fogg QA, Shoaib T. Where to find facial artery perforators: a
reference point. J Plast Reconstr Aesthet Surg 2010;63:2046–51.
niques are of little use in vessels with a calibre of less than
14 8. Bergeron L, Tang M, Morris SF. A review of vascular injection techniques
1 mm. We found that most perforators branch between the
for the study of perforator flaps. Plast Reconstr Surg 2006;117:2050–7.
site of the superior labial artery and the inferior labial artery
9. Manna F, Guarneri GF, Re Camilot MD, et al. An easy and cheap way of
or sublabial artery. These data suggest a landmark based on staining the arterial supply of the face: a preclinical study of visualization
the emergence of the labial arteries for the localisation of of facial vascular territories in human cadavers. J Craniomaxillofac Surg
2010;38:211–3.
mucosal perforators from the facial artery.
15,16 10. Whetzel TP, Saunders CJ. Arterial anatomy of the oral cavity: an analysis
Pribaz et al. described the FAMM flap for reconstruc-
of vascular territories. Plast Reconstr Surg 1997;100:582–90.
tion of the oral mucosa based on the facial artery. Matros
11. Shaw RJ, Batstone MD, Blackburn TK, et al. Preoperative Doppler
17
et al. reported a technique for placing the pedicle in patients assessment of perforator anatomy in the anterolateral thigh flap. Br J
with intact dentition to avoid two-stage reconstruction. Zhao Oral Maxillofac Surg 2010;48:419–22.
18 12. Demirseren ME, Afandiyev K, Ceran C. Reconstruction of the perioral
et al. described the buccinator myomucosal island flap for
and perinasal defects with facial artery perforator flaps. J Plast Reconstr
harvesting mucosa from the same zone for diverse recons-
Aesthet Surg 2009;62:1616–20.
tructions of the oral cavity and beyond. All these techniques
13. Furukawa M, Mathes DW, Anzai Y. Evaluation of the facial artery
eventually use perforators from the facial artery. on computed tomographic angiography using 64-slice multidetector
A thorough knowledge of vascular anatomy is crucial to computed tomography: implications for facial reconstruction in plastic
surgery. Plast Reconstr Surg 2013;131:526–35.
the understanding and designing of perforator flaps, and many
19–21 14. Karamessini MT, Kagadis GC, Petsas T, et al. CT angiography with three-
studies have been published recently. These perforator
dimensional techniques for the early diagnosis of intracranial aneurysms:
flaps allow primary closure of a defect and, more importantly,
Comparison with intra-arterial DSA and the surgical findings. Eur J
the use of the reconstructive principle of replacing tissues Radiol 2004;49:212–23.
like-with-like. 15. Pribaz J, Stephens W, Crespo L. A new intraoral flap: facial artery mus-
culomucosal (FAMM) flap. Plast Reconstr Surg 1992;90:421–9.
The concept of the mucosal perforator flap is not standard-
16. Pribaz JJ, Meara JG, Wright S, et al. Lip and vermilion reconstruc-
ised: at present, the only variables included in all definitions
22–25 tion with the facial artery musculomucosal flap. Plast Reconstr Surg
are the skin or subcutaneous tissue, or both. We have 2000;105:864–72.
shown that it is possible to make flaps based on the mucosal 17. Matros E, Swanson EW, Pribaz JJ. A modification of the facial artery
perforators from the facial artery, and our data may also help musculomucosal flap for palatal reconstruction in patients with intact
dentition. Plast Reconstr Surg 2010;125:645–7.
to improve the harvesting of flaps based on the facial artery
18. Zhao Z, Li S, Yan Y, et al. New buccinator myomucosal island
and on its mucosal perforators.
flap: anatomic study and clinical application. Plast Reconstr Surg
1999;104:55–64.
19. Morris SF, Tang M, Almutari K, et al. The anatomic basis of perforator
Conflict of interest flaps. Clin Plast Surg 2010;37:553–70.
20. Kannan RY, Mathur BS. Perforator flaps of the facial artery angiosome.
J Plast Reconstr Aesthet Surg 2013;66:483–8.
The authors have no financial interests in this research project
21. Lykoudis EG, Spyropoulou G-AC, Vlastou CC. The anatomic basis of
or in any of the techniques or equipment used in this study.
the gracilis perforator flap. Br J Plast Surg 2005;58:1090–4.
22. Blondeel PN, Van Landuyt KH, Monstrey SJ, et al. The Gent consensus
on perforator flap terminology: preliminary definitions. Plast Reconstr
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flap? Plast Reconstr Surg 2010;22(126):8–63.
1. Saint-Cyr M, Schaverien MV, Rohrich RJ. Perforator flaps: history, con-
24. Giunta R, Geisweid A. Defining perforator flaps: what is really perfo-
troversies, physiology, anatomy, and use in reconstruction. Plast Reconstr
rated? Plast Reconstr Surg 2002;109:1460–1.
Surg 2009;123:132e–45e.
25. Wei FC, Jain V, Suominen S, et al. Confusion among perforator flaps:
2. Lyons AJ. Perforator flaps in head and neck surgery. Int J Oral Maxillofac
what is a true perforator flap. Plast Reconstr Surg 2001;107:874–6.
Surg 2006;35:199–207.
Please cite this article in press as: Coronel-Banda ME, et al. Mucosal perforators from the facial artery. Br J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.bjoms.2014.03.013 Article Usage Dashboard
Mucosal perforators from the facial artery
Coronel-Banda, M.E.; Serra-Renom, J.M.; Lorente, M.; Larrea-Teran, W.P.
British Journal of Oral and Maxillofacial Surgery, Volume(s) 52, 04-Apr-2014, Pages 535-538
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Copyright © 2013 Elsevier B.V. All rights reserved. Terms and conditions Support
Int. J. Oral Maxillofac. Surg. 2015; 44: 29–33
http://dx.doi.org/10.1016/j.ijom.2014.07.022, available online at http://www.sciencedirect.com
Research Paper
Reconstructive Surgery
1
M. E. Coronel-Banda ,
1 2
J. M. Serra-Renom , M. Lorente ,
Cheek mucosa territories 3
W. P. Larrea-Tera´n
1
Institute of Aesthetic and Plastic Surgery Dr.
Serra-Renom, Hospital Quiro´n Barcelona,
2
perfused by perforators from the Barcelona, Spain; Laboratory of Functional
and Surgical Anatomy, Universitat
Internacional de Catalunya, Sant Cugat del
3
facial artery Valle`s, Spain; Milenium Corun˜a Medical
Centre, A Corun˜a, Spain
M. E. Coronel-Banda, J.M. Serra-Renom, M. Lorente, W.P. Larrea-Tera´n: Cheek
mucosa territories perfused by perforators from the facial artery. Int. J. Oral
Maxillofac. Surg. 2015; 44: 29–33. # 2014 International Association of Oral and
Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Abstract. The cutaneous areas perfused by the cutaneous perforators of the facial
artery have been well defined. However, the oral mucosal areas perfused by
perforators of the facial artery have not been described. We studied 20 hemifaces
from 10 cadavers. Perforators between the branching off sites of the labial arteries
larger than 0.5 mm were selected and their diameters were measured; the distance
between their exit point over the facial artery and the branching-off point from the
superior labial artery was also measured. The selected perforators were injected
with 1 ml of diluted ink. Both labial arteries were ligated to limit the study to the
mucosal perforators from the facial artery. Seventy-four perforators from 20
hemifaces were studied; the mean diameter was 0.58 mm and the mean number per
Keywords: facial artery; mucosal perfora-
artery was 3.7. The total stained area, a triangle-shaped zone on the cheek, was
somes; oral mucosa; surgical flaps.
determined. The more constant perforators larger than 0.5 mm were localized next
to the branching-off site of the superior labial artery. With this information, flaps Accepted for publication 9 July 2014
based on the mucosal perforators from the facial artery could be designed. Available online 11 September 2014
The use of oral mucosal flaps from the deriving from the facial artery, and also performed and all superficial perforators
internal side of the cheek area to recon- to determine their number, location, the that could be identified were ligated. The
struct oral defects has been well described mean perfused area, and their distribution. facial arteries were dissected from the base
1–4
by many authors. All these flaps are of the jaw up to the branching-off point
based on the facial artery and its branches. from the upper labial artery. Oral mucosal
Materials and methods
However, their vascular territories have perforators from the facial artery between
5
not been established. Qassemyar et al. Twenty hemifaces from 10 fresh-frozen the branching-off points of the superior and
have described the cutaneous territories cadavers were used. The skin incisions inferior labial arteries that were larger than
perfused by perforators from the facial followed a facelift pattern. Two incisions 0.5 mm were selected (Fig. 1).
artery. However, the facial artery perfora- were added, the first from a ‘crow’s foot’ The superior labial artery (SLA) and the
tors of the oral mucosa and the intraoral to the ipsilateral tragus, and the second inferior labial artery (ILA) were ligated
mucosal territories dependent on these from four finger widths below the hori- after identification. Their branching-off
perforators have not been described. zontal branch of the jaw. points were determined. The posterior
The objective of this study was to A supra-superficial musculoaponeuro- buccal branch of the facial artery was also
describe the oral mucosal perforasomes tic system (SMAS) dissection was ligated.
0901-5027/01029 + 05 # 2014 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
30 Coronel-Banda et al.
limits (TL) were also obtained with 95%
confidence, such that 95% of the general
population are within the limits deter- mined.
Results
The mean length of the facial artery from
the base of the jaw to the exit point of the
SLA was 62.70 6.18 mm. The diameter
Æ
of the facial artery was 2.74 0.38 mm at
Æ
the base of the jaw, 1.76 0.27 mm at the
Æ
oral commissure, and 1.28 0.24 mm at
Æ
the bifurcation of the SLA. The mean
number of perforators larger than
0.5 mm was 3.70 1.22. In six cases
Æ
we found a fifth oral mucosal perforator,
Fig. 1. Dissection of the facial artery tree and identification of its branches; several inserts beneath and in one case a sixth (Table 1).
the facial artery perforators are shown (light blue). Note the guide points on the gonion (G) and The SLA branched bilaterally from the
pogonion (P). The site corresponding to the oral commissure is shown with a green guide point. facial artery in all cases. Taking the oral
commissure as reference, the branching-
off site of the SLA was identified 7.4 mm
Descriptive anatomy colouring was observed, the area was laterally and 5.1 mm above a line parallel
identified and measured using the software to the lower edge of the jaw, between the
The length of the facial artery was mea-
ImageJ version 1.45s (Fig. 2). gonion and pogonion. Using inferential
sured from the lower edge of the jaw to the
statistics, we predicted the point of emer-
exit point of the SLA. The diameter of the
gence of the upper labial artery within an
facial artery was measured at the base of 2
Statistical analysis area of 3 cm in the general population
the jaw, the oral commissure, and the exit
(Table 2).
point of the SLA. The number of oral Stata software program was used for the
The ILA was present bilaterally in eight
mucosal perforators was identified, as statistical analysis (StataCorp LP, College
of 10 heads. In the other two cases, the
was their origin over the facial artery, Station, TX, USA). The Shapiro–Wilk test
sub-labial artery was identified. The mean
taking the branching-off site of the SLA and the normal probability plot technique
point of emergence of the ILA was
as a starting point. were performed to assess the normality of
9.60 mm above the lower edge of the
Three landmark points were identified: the variables. If the distribution of the
jaw, on a line from the gonion to the
the gonion, the pogonion, and the oral variables was normal, the Pearson’s test
pogonion, and 24.19 mm lateral to the oral
commissure. A line was traced between was used. When distribution was non-nor-
commissure. Statistical tolerance limits
gonion and pogonion at the base of the mal, Spearman’s rank correlation coeffi-
were 3 cm in the first case and 5 cm in
jaw, and another parallel line starting from cient was used to evaluate the results.
the second (Table 2).
the oral commissure (Fig. 1). To determine the branching-off sites of
Seventy-four perforators were mea-
Perforators larger than 0.5 mm were the SLA and ILA, the guide points de-
sured. The mean diameter of the perfora-
selected and perfused with 1 ml of diluted scribed previously were used. Means,
tors at the branching-off site from the
ink. After each injection, the presence of standard deviations, and 95% confidence
facial artery was 0.58 0.19 mm. The
colour in the oral mucosa was examined. If intervals (CI) were calculated. Tolerance Æ
74 perforators were perfused and the mean
area per perforator was
2
279.72 156.24 mm . The perforators
Æ
were measured from the branching-off site
from the SLA, and only those larger than
0.5 mm were selected (Table 3).
The first two perforators were found in
all cases. The first perforator was found at
a mean distance of 4.51 2.90 mm, and
Æ
the second at a mean of 10.34 4.19 mm.
Æ
In 16 cases a third perforator was found at
a mean of 16.65 4.01 mm, in 11 cases a
Æ
fourth was found at a mean of
23.10 5.23 mm, in six cases a fifth
Æ
was found at 31.74 5.31 mm, and in
Æ
one case a sixth was found at 40.92 mm.
The perfused areas in the oral mucosa
were classified into six main types: three
anterior areas near the oral commissure
Fig. 2. Areas of the cheek stained by the mucosal perforators from the facial artery. Note the and the lips (superior, medial, and inferi-
four perforasomes: two anterior (black arrows) and two middle. or), two middle areas (superior and inferi-
Cheek mucosa territories perfused by perforators 31
Table 1. General description of the facial artery.
FA diameter FA diameter Length of the
Dissection FA diameter at at the oral at the origin FA from mandible Number of
number Sex the mandible (mm) commissure (mm) of the SLA (mm) to SLA (mm) FAPM > 0.5 mm
1 M 2.30 1.90 0.90 62.30 2
2 M 2.98 1.50 1.25 52.20 2
3 M 3.65 1.71 1.37 59.05 2
4 M 2.74 1.91 0.98 57.93 5
5 M 2.44 1.61 1.25 63.98 6
6 M 2.55 1.90 1.11 64.58 5
7 M 2.51 1.62 1.23 63.30 5
8 M 2.71 1.68 0.96 64.96 3
9 F 2.86 1.64 1.20 66.22 3
10 F 2.23 1.76 1.10 61.71 3
11 F 2.24 1.56 0.97 65.23 5
12 F 2.51 1.59 1.28 74.77 3
13 F 2.73 2.03 1.35 60.72 3
14 F 2.50 1.85 1.70 58.98 4
15 M 3.06 1.71 1.67 65.19 4
16 M 2.62 1.63 1.59 74.87 4
17 F 3.51 2.68 1.58 67.43 4
18 F 2.67 1.87 1.49 64.27 5
19 F 2.96 1.61 1.27 49.56 4
20 F 3.03 1.42 1.39 56.82 2
Mean 2.74 1.76 1.28 62.70 3.70
SD 0.37 0.27 0.23 6.03 1.19
FA, facial artery; SLA, superior labial artery; FAPM, facial artery perforators of the oral mucosa; M, male; F, female; SD, standard deviation.
Table 2. Statistical analysis of measurements relative to guide points. Inferential statistics to determine the branching-off site of the superior labial
artery and the inferior labial artery in the general population from our sample, with a 95% confidence interval.
Number of Mean value 95% CI 95% TL
Artery Surface landmark dissections (mm) SD (mm) P < 0.05 P < 0.05
Superior labial artery Oral commissure Lateral 20 7.40 3.63 1.70 9.98
a Æ Æ Æ
Oral commissure Superior 20 5.12 2.76 1.29 7.60
Æ Æ Æ
Inferior labial artery Oral commissure Lateral 20 24.19 8.95 4.19 24.63
Æ Æ Æ
Base of jaw Superior 20 9.60 5.46 2.56 15.04
Æ Æ Æ
SD, standard deviation; CI, confidence interval; TL, tolerance limits.
a
A line parallel to the base of the jaw was used.
Table 3. Analysis of mucosal perforators in order of appearance. Distribution of the 74 areas found in the 20 dissected hemifaces and anatomical
a
localization: three anterior zones, two middle zones, and one posterior zone.
FAPM origin
FAPM over the course Coloured skin
2
position n of FA (mm) Diameter (mm) Anatomical localization surface (mm )
1st 20 4.51 2.90 0.52 0.20 45.0% Antero-superior 90% Anterior zones 379.23 182.55 Æ Æ Æ
45.0% Antero-medial
10.0% Middle superior 10% Middle zone
2nd 20 10.34 4.19 0.55 0.21 35.0% Antero-medial 65% Anterior zones 305.83 161.84 Æ Æ Æ
30.0% Antero-inferior
20.0% Middle superior 30% Middle zones
10.0% Middle inferior
5.0% Posterior
3rd 16 16.65 4.01 0.52 0.19 25.0% Antero-inferior 25% Anterior zones 187.02 73.25
Æ Æ Æ
50.0% Middle superior 69% Middle zones
18.8% Middle inferior
6.3% Posterior 6% Posterior zone
4th 11 23.10 5.23 0.49 0.15 36.4% Middle superior 82% Middle zones 235.05 99.77
Æ Æ Æ
45.5% Middle inferior
18.2% Posterior 18% Posterior zone
5th 6 31.74 5.31 0.49 0.13 50.0% Middle inferior 211.12 105.58 Æ Æ Æ
50.0% Posterior
6th 1 40.92 100.0% Posterior 153.36
Total 74 0.53 0.19 279.72 156.24
Æ Æ
FAPM, facial artery perforators of the oral mucosa; FA, facial artery.
a
Measurement starting from the bifurcation of the superior labial artery. Results are expressed in millimetres as the mean standard deviation. Æ
32 Coronel-Banda et al.
Similarly, we may assume that the perfu-
sion of the posterior perforasome is pro-
vided by another source, probably the
buccal artery or the anastomosis between
the buccal artery and facial artery de-
3
scribed by Zhao et al.
In the case where only two or three
perforators larger than 0.5 mm were
found, the total stained area invariably
reproduced the triangle-shaped zone be-
tween the canines and a point halfway
along a line between the second and third
upper and lower molars. All of the cheek
mucosa inside that triangle could probably
be elevated as a flap on these two or three
Fig. 3. Diagram of the oral mucosa perforasomes. The anterior area is divided into three areas,
perforators. The blood supply to the whole
the middle area into two areas, and the posterior area is not divided. The total area of oral mucosa
mucosa triangle would be provided by the
perfused is between the canines and a point halfway along a line between the second and the
third upper and lower molars. direct and indirect linking vessels, as de-
15,16
scribed for other perforator flaps.
The arterial perfusion of the oral muco-
or), and one near the molars (posterior) branching-off points of the SLA and the sa of the cheek has been described by
17
(Fig. 3). ILA. Whetzel and Saunders. They proposed
8
In most cases the first and second per- Ng et al. described a reference point for that its primary perfusion was provided by
forators perfused the anterior zone per- locating cutaneous facial artery perfora- the buccal and labial arteries. We have
forasomes (90% and 65%, respectively), tors. In this study, in accordance with demonstrated that the oral mucosa is per-
whereas the third and fourth perfused the other reports, we used the emergence of fused directly by perforators of the facial
middle zone perforasomes (69% and 82%, the SLA as a landmark because of the artery.
respectively). The posterior perforasome reliability and consistency of its branch- The sum of all perforasomes corre-
9,10
had various origins (Table 3). ing-off point. We did not use the ILA sponds to the area described previously
The total stained area corresponded to a as a landmark because of the greater vari- by Whetzel, initially assigned to the labial
triangle of oral mucosa located between ability of the artery, as described previ- arteries and buccal artery. In our cases we
11
the canines and a point halfway along a ously by Edizer et al. The branching-off ligated them intentionally. The posterior
line between the second and third upper site of the ILA was less predictable. Sta- perforasome probably shares perfusion
and lower molars (Fig. 3). tistically, the branching-off site may be with the buccal artery. This could explain
2
found in an area of around 15 cm . the diverse sources of perfusion for the
Using inferential statistics we were able posterior territory.
to predict the branching-off site of the The facial artery musculo-mucosal
Statistical analysis 1,4
SLA in an area 2 cm long and 1.5 cm high (FAMM) flap is a very reliable and
2
There was a statistically significant corre- with a surface area of 3 cm for 95% of the useful axial flap based on the facial artery.
lation between the diameter of the artery at general population. This method was However, the maximum amount of muco-
12
the base of the jaw and at its branching-off reported by Whetzel and Mathes for sa that can be harvested has not been
2
point from the SLA (P < 0.05). the description of certain perforators of described. Landes et al. have described
Spearman’s rank correlation coefficient the facial region and reproduces the pre- the dorsally pedicled buccal musculo-mu-
9
showed a significant inverse correlation vious findings of Nakajima et al. and cosal (DPBM) flap and stated that this flap
13
between the distance from the exit point Pinar et al. is supported by the submucosal plexus
of the perforators starting at the branching- The perfused areas coincided with the and, for that reason, a thin layer of bucci-
off point of the SLA and the stained areas number of mucosal perforators found. Af- nator is included to preserve that plexus.
of the oral mucosa (P < 0.001). ter studying the 74 stained territories in all We could assume that the plexus is even-
of the cadavers, it was clear that the tually supported by the musculo-mucosal
perfusion was different in each cheek, perforators from the facial artery. Zhao
Discussion 3
and even in the same corpse. They were et al., as a refinement of the flap described
18 19
A vascular territory nourished by a single most consistently found in the anterior by Bozola et al. and Carstens et al.,
perforator, or a ‘perforasome’, is a concept areas. The first pair of perforators perfused described in detail the buccinator muscu-
6
developed by Saint-Cyr et al. This con- mainly the anterior perforasomes and the lar mucosal system, and also described the
cept can help define precise territories for next two the medial perforasomes. This arterial distribution of the buccinator mus-
the creation of flaps for reconstruction. may be because, in the light of previous cle. However, they did not describe either
In a previous work we characterized the descriptions, it was decided to select only the oral mucosal perforators of the facial
14
perforators from the facial artery with mucosal perforators larger than 0.5 mm. artery or the areas they perfuse.
7
latex. In the present study we identified The mean area perfused by each perfo- In this paper, we have described the
2
each perfused area or ‘mucosal perfora- rator was 279.72 mm , notably lower than maximum amount of mucosa that can be
some’ with diluted ink. Likewise, we ob- the cutaneous territories. The six areas of harvested to perform a reconstruction,
served that the majority of perforators perfusion reproduce the pattern described reflected by the perfusion of the cheek
4
from the facial artery for the oral mucosa in the skin and are compatible with the mucosa by the perforators deriving from
6
of the cheek were localized between the perforasome theory of Saint-Cyr et al. the facial artery. We have reported a map
Cheek mucosa territories perfused by perforators 33
of the six areas perfused by the mucosal 3. Zhao Z, Li S, Yan Y, Li Y, Yang M, Mu L, 14. Hofer SO, Posch NA, Smit X. The facial
perforators of the facial artery. The most et al. New buccinator myomucosal island artery perforator flap for reconstruction of
reliable are the anterior and medial areas. flap: anatomic study and clinical application. perioral defects. Plast Reconstr Surg
Plast Reconstr Surg 1999;104:55–64. 2005;115:996–1003.
The total stained area of oral mucosa
4. Hatoko M, Kuwahara M, Tanaka A, Yurugi 15. Wong C, Saint-Cyr M, Rasko Y, Mojallal A,
perfused by the perforasomes from the
S. Use of facial artery musculomucosal flap Bailey S, Myers S, et al. Three- and four-
facial artery describes a triangular-shaped
for closure of soft tissue defects of the dimensional arterial and venous perfora-
area that could be selected to design made-
mandibular vestibule. Int J Oral Maxillofac somes of the internal mammary artery per-
to-measure flaps.
Surg 2002;31:210–1. forator flap. Plast Reconstr Surg
5. Qassemyar Q, Havet E, Sinna R. Vascular 2009;124:1759–69.
Funding basis of the facial artery perforator flap: 16. Bailey SH, Saint-Cyr M, Wong C, Mojallal
analysis of 101 perforator territories. Plast A, Zhang K, Ouyang D, et al. The single
The authors have no financial interests in
Reconstr Surg 2012;129:421–9. dominant medial row perforator DIEP flap in
this research project or in any of the tech-
6. Saint-Cyr M, Wong C, Schaverien M, Mojal- breast reconstruction: three-dimensional
niques or equipment used in this study. lal A, Rohrich RJ. The perforasome theory: perforasome and clinical results. Plast
vascular anatomy and clinical implications. Reconstr Surg 2010;126:739–51.
Plast Reconstr Surg 2009;124:1529–44. 17. Whetzel TP, Saunders CJ. Arterial anatomy
Competing interests
7. Coronel-Banda ME, Serra-Renom JM, Lor- of the oral cavity: an analysis of vascular
The authors have no competing interests in ente M, Larrea-Tera´n WP. Mucosal perfora- territories. Plast Reconstr Surg
this study. tors from the facial artery. Br J Oral 1997;100:582–7. discussion 588–590.
Maxillofac Surg 2014. [Epub ahead of print]. 18. Bozola AR, Gasques JA, Carriquiry CE,
8. Ng ZY, Fogg QA, Shoaib T. Where to find Cardoso de Oliveira M. The buccinator mus-
Ethical approval facial artery perforators: a reference point. J culomucosal flap: anatomic study and clini-
Plast Reconstr AesthetSurg 2010;63:2046–51. cal application. Plast Reconstr Surg
Ethical approval was not required by our
institution. 9. Nakajima H, Imanishi N, Aiso S. Facial 1989;84:250–7.
artery in the upper lip and nose: anatomy 19. Carstens MH, Stofman GM, Hurwitz DJ,
and a clinical application. Plast Reconstr Futrell JW, Patterson GT, Sotereanos GC.
Patient consent Surg 2002;109:855–61. discussion 862–863. The buccinator myomucosal island pedicle
10. Mag˘den O, Edizer M, Atabey A, Tayfur V, flap: anatomic study and case report. Plast
Patient consent was not required in this
Ergu¨r I˙.. Cadaveric study of the arterial Reconstr Surg 1991;88:39–50.
study.
anatomy of the upper lip. Plast Reconstr
Surg 2004;114:355–9. Address:
˘ Mauricio E. Coronel-Banda
References 11. Edizer M, Magden O, Tayfur V, Kiray A,
Ergu¨r I, Atabey A. Arterial anatomy of the Institute of Aesthetic and Plastic Surgery Dr.
Serra-Renom
1. Pribaz J, Stephens W, Crespo L. A new lower lip: a cadaveric study. Plast Reconstr
Hospital Quiro´n Barcelona
intraoral flap: facial artery musculomucosal Surg 2003;111:2176–81.
Plaza Alfonso Comı´n
(FAMM) flap. Plast Reconstr Surg 12. Whetzel T, Mathes S. Arterial anatomy of
5–7
1992;90:421–9. the face: an analysis of vascular territories
08023 Barcelona
2. Landes CA, Seitz O, Ballon A, Stu¨binger S, and perforating cutaneous vessels. Plast
Spain
Robert S, Kova´cs AF. Six years clinical Reconstr Surg 1992;89:591–603.
Tel.: +34 93 284 81 89; Fax: +34 93 284 81 89
experience with the dorsally pedicled buccal 13. Pinar YA, Bilge O, Govsa F. Anatomic study
E-mail: [email protected]
musculomucosal flap. Ann Plast Surg of the blood supply of perioral region. Clin
2009;62:645–52. Anat 2005;18:330–9. Article Usage Dashboard
Cheek mucosa territories perfused by perforators from the facial artery
Coronel-Banda, M.E.; Serra-Renom, J.M.; Lorente, M.; Larrea-Teran, W.P.
International Journal of Oral and Maxillofacial Surgery, Volume(s) 44, 11-Sep-2014, Pages 29-33
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Copyright © 2013 Elsevier B.V. All rights reserved. Terms and conditions Support VIEWVIEWPOINTSPOINTS
GUIDELINES simulation allows development of these skills, reducing Viewpoints, pertaining to issues mistakes, shortening surgical time, and improving re- of general interest, are welcome, sults in vivo.4 We performed a surgical simulation ex- even if they are not related to perimental study, evaluating traditional and modified items previously published. View- auricular templates as guides for carving ear frame- points may present unique tech- niques, brief technology up- works on Ipomoea batatas, comparing and analyzing the dates, technical notes, and so on. obtained results. Viewpoints will be published on The traditional templates were based on sheets of a space-available basis because they are typically less time- paper and sketched lines representing the main struc- sensitive than Letters and other types of articles. Please tures of the external ear (i.e., helix, antihelix, tragus, note the following criteria: antitragus, triangular fossa, scaphoid fossa, and con- Text—maximum of 500 words (not including cha) (Fig. 1). The proposed modified templates were F1 • references) References—maximum of five based on paper sheets, with lines representing the main • Authors—no more than five structures and markings detailing the depths of each of • Figures/Tables—no more than two figures and/or one these structures as follows: whole painted, striped, and • table unpainted (meaning deep, not deep, and elevated, re- Authors will be listed in the order in which they appear spectively). The striped lines, at the same time, repre- in the submission. Viewpoints should be submitted elec- sented more depth when drawn closer together (Fig. 1). tronically via PRS’ enkwell, at www.editorialmanager.com/ prs/. We strongly encourage authors to submit figures in Ipomoea batatas, also known as sweet potato, was color. used because of its similarity in consistency and We reserve the right to edit Viewpoints to meet re- flexibilityFig. 1. Preparation to human with latex rib showing cartilage. the5 facialEach artery sweet perfora- po- quirements of space and format. Any financial interests tatotor after model crossing was the referred muscle and to reaching as an the individual oral mucosa. case. relevant to the content must be disclosed. Submission of Five common carving tools with different curves a Viewpoint constitutes permission for the American So- ciety of Plastic Surgeons and its licensees and assignees to and angles were used to sculpt the models. Eight publish it in the Journal and in any other form or medium. novel surgeons were tested; half of them used the The views, opinions, and conclusions expressed in the traditional template and the other half used the Viewpoints represent the personal opinions of the indi- modified template. The exercise was repeated vidual writers and not those of the publisher, the Editorial Board, or the sponsors of the Journal. Any stated views, twice. The resulting auricular sculptures were eval- opinions, and conclusions do not reflect the policy of any uated based on aesthetic results, ranked according of the sponsoring organizations or of the institutions with to resemblance to the real ear model, being clas- which the writer is affiliated, and the publisher, the Edi- sified as poor, fair, or good results. torial Board, and the sponsoring organizations assume no responsibility for the content of such correspondence. Aesthetically different auricular frameworks were obtained using the two different types of templates. Better definition of three-dimensional Viewpoints structures (i.e., helix, antihelix, tragus, antitragus, scaphoid fossa, triangular fossa, and concha) and AQ: 1 AModifiedTemplateforMicrotiaReconstructionViewpoints better aesthetic results were obtained using the Tested by Surgical Simulation on Ipomoea batatas modified template (n ϭ 16). MucosalSir: Perforasomes Sir: icrotia reconstruction is a challenge for plastic Mhesurgeons use of the because term “perforator of its variable flap” clinical is controver presen-- tationsial. and1 According difficult surgical to the reconstruction.Ghent consensus1 Although study,2 T Fig. 2. Blue latex preparation with several perforators between “aseveral perforator reconstructive flap is a methods flap consisting have been of skin proposed, and/ the emergence of the superior labial artery and the lower lip orreconstruction subcutaneous with fat. autologous The vessels costal that cartilage,supply blood as elab- to (arrowheads). The oral commissure is marked in green. theorated flap and are isolated modified perforator(s). by Tanzer, Brent, These and perforators Nagata, remains the best option with which to obtain favorable may pass either through or in between the deep tis- results with fewer complications than other reconstruc- 5 suestive options.(mostly2 muscle).” The study also states that even In our previous work, we demonstrated the exis- if theThe skin three-dimensional is not included, topography the flap can of the be externalformed tence of direct perforators (Fig. 1) from the facial byear Scarpa’s accurately fascia reflects and thesubcutaneous shape of the fat. internal The current carti- artery crossing through the muscle to reach the oral definitionslaginous skeleton. of perforator3 Reproducing flaps anatomical do not include and struc- the mucosa. These perforators irrigate specific mucosal onestural detailsthat terminate of the external in the earmucosa, is a challenge only those for that any territories, thus conforming to Saint-Cyr’s definition of endplastic in surgeonthe skin. and3,4 requires a high level of surgical skill a perforasome. and training to fulfill the patient’s expectation. Surgical We performed a systematic review of the literature through the PubMed database searching for articles Copyright ©2012© 2013 byby thethe AmericanAmerican SocietySociety of Plastic Surgeons Fig.with 1. theTraditional keywords and modified “perforator auricular mucosa,” templates. “mucosal
www.PRSJournal.comwww.PRSJournal.com 1081e1 Color Figure(s): F1-21 Art: PRS204746 Input-nlm/4 18:01 12/13/8 8؍rich3/zpr-prs/zpr-prs/zpr01012/zpr6009-12a angnes S Plastic and Reconstructive Surgery s $ECEMBER perforator,” “oral mucosa perforator,” “oral muco- Presented in part at the II International Training sal perforator,” “oral mucosa perforator flap,” and Course in Aesthetic Surgery, Barcelona, Spain, April “oral mucosal perforator flap.” In all, 17 articles were OF identified. In the same database, we searched for the keywords DISCLOSURE “perforasome” and “perforasomes”; in all, 16 articles The authors have no financial interests in this research were identified. We examined each of the references to see whether they described mucosal perforator flaps, project or in any of the techniques or equipment used in this mucosal perforators, or mucosal perforasomes. None study. of the references quoted in these articles mentioned mucosal perforators or their perforasomes. Perforators are penetrating arteries that emerge REFERENCES from a main vessel, pass through the muscle or another 3INNA 2 "OLOORCHI ! -AHAJAN !, 1ASSEMYAR 1 2OBBE - anatomic structure, and reach the skin or subcutane- What should define a “perforator flap”? Plast Reconstr Surg. ous tissue.1–4 Perforators and perforasomes have been n described in other areas, but none of the current defi- "LONDEEL 0. 6AN ,ANDUYT +( -ONSTREY 3* ET AL 4HE nitions identify the mucosa as a final destination of a h'ENTv CONSENSUS ON PERFORATOR mAP TERMINOLOGY 0RELIMI- perforator artery. nary definitions. Plast Reconstr Surg n In view of the absence of references in the literature, QUIZ DISCUSSION we propose the concept of the “mucosal perforasome,” a 7EI &# *AIN 6 3UOMINEN 3 #HEN (# #ONFUSION AMONG unique vascular territory irrigated by a perforator artery PERFORATOR mAPS 7HAT IS A TRUE PERFORATOR mAP Plast Reconstr in the mucosa. This concept may be useful because it Surg n allows a clearer understanding of the blood supply of 'IUNTA 2 'EISWEID ! $ElNING PERFORATOR mAPS 7HAT IS the areas of mucosa in general; it can guide the creation really perforated? Plast Reconstr Surg n of flaps of this kind and differentiates them clearly from author reply 1461. perforator flaps described in the skin. #ORONEL "ANDA -% 3ERRA 2ENOM *- ,ORENTE - ,ARREA 4ERÉN Our findings may stimulate the search for similar WP. Cheek mucosa territories irrigated by perforators from the mucosal areas elsewhere in the body. The observa- FACIAL ARTERY !N ANATOMICAL STUDY Submitted for publication. tion of specific areas in the mouth may be replicated in other sites where reconstruction of the mucosa lin- ing is needed, following the principle of “like with An Easy and Applicable Method for Capturing like” tissue. High-Quality Rhinoplasty Videos: Handle These flaps have smaller-caliber perforators than their counterparts in the skin, at least in the area of the Banded Camcorder mouth. It remains to be determined whether in other Sir: areas of the body the same configuration exists. The ntraoperative digital video recording is necessary identification of these areas may be extremely useful Ifor presenting your work, teaching, research, audit- in the reconstruction of intestinal, genitourinary, and ing, and patient education.1 However, capturing high- genital mucosa. quality video during rhinoplasty is challenging.2 We The oral mucosa presents well-defined terri- describe an effective and practical recording method tories, each mainly irrigated by a single perforator based on the use of a camcorder attached to a surgical (Fig. 2), which we term “mucosal perforasomes.” In light handle. this article, we present a definition of the term. For recordings, we used a commercially available $/) 023BEA HIGH DElNITION DIGITAL VIDEO CAMCORDER 3ONY ($2 Mauricio E. Coronel-Banda, M.D. #8% ($ (ANDYCAM #AMCORDER &IRST THE CAM- ERA WAS PUT INTO A STERILE PLASTIC BAG AND THE ADJUSTABLE Jose M. Serra-Renom, M.D., Ph.D. video screen was turned toward the surgeon. Then, the Marian Lorente, M.D. part of the bag covering the lens was cut with scissors. Universitat Internacional de Catalunya The covered camera was attached to the operating light handle using a sterile drape. The sterile light han- Wendy P. Larrea-Terán, M.D., M.Sc. dle was then attached to the surgical light. This sterile Universidad Complutense de Madrid and mobile camera system allows either an assistant or Barcelona, Spain A GLOVED SURGEON TO ADJUST THE CAMERAS lELD OF VIEW #ORRESPONDENCE TO $R 3ERRA 2ENOM without contamination (Fig. 1). Institute of Aesthetic and 0LASTIC 3URGERY $R 3ERRA 2ENOM Hospital Quirón Barcelona Universitat Internacional de Catalunya Supplemental digital content is available for this article. Plaza Alfonso Comín, 5–7 $IRECT 52, CITATIONS APPEAR IN THE TEXT ON 023*OURNAL "ARCELONA 3PAIN COM SIMPLY CLICK THE 52, TO ACCESS THIS MATERIAL [email protected]
1082e Plastic and Reconstructive Surgery s *ANUARY
)T ALLOWS RAPID MANIPULATION AND UNDERSTANDING OF AN Reconstruction of Nasal Septal Perforations in INDIVIDUALS ANATOMY BY PHYSICALLY HOLDING THE OBJECT Cocaine-Addicted Patients with Facial Artery AND BEING ABLE TO VISUALIZE IT IN MULTIPLE PLANES 4HIS Mucosa-Based Perforator Flap CAN BE USEFUL FOR TEACHING LEARNERS AND CAN BE USED Sir: AS A TOOL TO BETTER EXPLAIN THE PROPOSED SURGERY TO EPTAL PERFORATION IS ONE OF THE MOST FREQUENT COM PATIENTS USING THEIR OWN ANATOMY SPLICATIONS OF SNORTING COCAINE ! WIDE RANGE OF /NE LIMITATION OF THE PROCESS IS THE COST ASSOCIATED MUCOSAL DEFECTS HAVE BEEN DESCRIBED FROM A CLINI WITH PRODUCTION OF THE MODEL WHICH CAN BE ANYWHERE CALLY ASYMPTOMATIC STATE THROUGH PINPOINT HOLES TO THE FROM TO !LSO DUE TO THE MINUTENESS OF DESTRUCTION OF THE DORSAL SUPPORT OR EVEN THE DESTRUC PERFORATOR VESSELS SOME SMALLER VESSELS DO NOT ENDURE TION OF THE MAXILLA THE PRINTING PROCESS DUE TO THE RESOLUTION LIMITATIONS 6ARIOUS TYPES OF LOCAL mAPS HAVE BEEN TESTED FOR OF THE THREE DIMENSIONAL PRINTER 4HIS CAN BE AMELIO RECONSTRUCTION OF THE NASAL SEPTUM "ECAUSE OF THE RATED WITH A LARGER MODEL ALBEIT AT A HIGHER COST !LSO HIGH RISK OF FAILURE DUE TO DAMAGE TO ADJACENT TIS THE MATERIALS USED TO MAKE CERTAIN MODELS ARE DELICATE SUE THE USE OF DISTANT TISSUES OR EVEN DISTANT FREE AND ROUGH HANDLING CAN CAUSE PERFORATOR BRANCHES TO mAPS IS PREFERRED 4HE PROBLEM WITH REMOTE OR FREE CRACK (OWEVER POSTPRINTING PROCESSING WITH MATERIALS mAPS IS THAT THEIR VOLUME MAY BE EXCESSIVE AND THEY SUCH AS WAX CAN CREATE A DURABLE MODEL THAT CAN BE MAY OBSTRUCT THE PASSAGE OF AIR /THER AUTHORS HAVE USED IN CLINICS AND TEACHING SESSIONS DESCRIBED USEFUL MUCOSAL REGIONAL mAPS SUCH AS THE $/) PRS FACIAL ARTERY MUSCULOMUCOSAL AN AXIAL mAP CENTERED Joshua A. Gillis, B.Sc., M.D. OVER THE FACIAL ARTERY OR THE BUCCINATOR mAP BASED ON THE POSTERIOR BUCCAL ARTERY OR THE ANTERIOR SEGMENT OF Steven F. Morris, M.D., M.Sc. THE FACIAL ARTERY $IVISION OF 0LASTIC 3URGERY !NATOMICAL STUDIES PERFORMED BY OUR GROUP HAVE $ALHOUSIE 5NIVERSITY (ALIFAX .OVA 3COTIA #ANADA IDENTIlED DIRECT PERFORATORS FROM THE FACIAL ARTERY IRRIGATING SPECIlC MUCOSAL TERRITORIES /N THE BASIS #ORRESPONDENCE TO $R -ORRIS OF THESE lNDINGS WE HAVE DESIGNED AN ISLAND mAP BY $IVISION OF 0LASTIC 3URGERY SELECTING THE AREAS WITH THE BEST VASCULARIZATION THAT $ALHOUSIE 5NIVERSITY IS THE ANTERIOR AND MIDDLE FACIAL ARTERY PERFORASOMES 3UMMER 3TREET OF THE ORAL MUCOSA 4O OUR KNOWLEDGE THIS IS THE lRST (ALIFAX .OVA 3COTIA "( ! #ANADA DESCRIPTION IN THE LITERATURE OF A MUCOSA BASED PERFORA SFMORRIS GMAILCOM TOR mAP 5SING $OPPLER SONOGRAPHY WE MARK THE PATH OF THE FACIAL ARTERY IN THE ORAL MUCOSA 7E HARVEST THE DISCLOSURE MUSCULOMUCOSAL mAP BY EXTRACTING AN AREA ABOUT The authors have no financial interest in any of the prod- PERCENT LARGER THAN THE DEFECT THAT WE AIM TO COVER ucts or devices mentioned in this article. 7E ATTEMPT TO LIGATE THE FACIAL ARTERY IN THE GINGI VAL SULCUS TAKING CARE NOT TO DAMAGE THE PERFORATORS NEXT TO THE BUCCINATOR AND ORBICULARIS MUSCLES 7E REFERENCES PERFORM A RETROGRADE DISSECTION OF THE FACIAL ARTERY TAKING EXTREME CAUTION AT THE BRANCHING OFF SITE OF THE 2ENGIER & -EHNDIRATTA ! VON 4ENGG +OBLIGK ( ET AL SUPERIOR LABIAL ARTERY BIFURCATION 4HE EXIT POINT OF THE $ PRINTING BASED ON IMAGING DATA 2EVIEW OF MEDI CAL APPLICATIONS Int J Comput Assist Radiol Surg SUPERIOR LABIAL ARTERY WILL BE ¢ MM LATERALLY AND n ¢ MM ABOVE THE ORAL COMMISSURE IN A LINE PAR +LAMMERT 5 "ÚHM ( 3CHWEITZER 4 ET AL -ULTI DIRECTIONAL ALLEL TO THE LOWER EDGE OF THE JAW BETWEEN THE GONION ,E &ORT ))) MIDFACIAL DISTRACTION USING AN INDIVIDUAL AND POGONION PERCENT TOLERANCE LIMITS 4HE AREA PREFABRICATED DEVICE J Craniomaxillofac Surg MEASURES APPROXIMATELY CM n /NCE WE REACH THE BIFURCATION OF THE SUPERIOR +LAMMERT 5 'BURECK 5 6ORNDRAN % 2ÚDIGER * LABIAL ARTERY WE LIGATE IT AND CONTINUE THE DISSECTION -EYER -ARCOTTY 0 +àBLER !# $ POWDER PRINTED CAL OVER THE FACIAL ARTERY TO THE BASE OF THE NASAL ALA OR TO A CIUM PHOSPHATE IMPLANTS FOR RECONSTRUCTION OF CRANIAL POINT WHERE WE CAN EASILY INSERT OUR mAP INSIDE THE NOSE AND MAXILLOFACIAL DEFECTS J Craniomaxillofac Surg &IG /N THE SEPTAL ORIlCE WE EXCISE THE BORDERS OF n THE DEFECT UNTIL WE lND HEALTHY TISSUE AND ATTACH OUR ,I " :HANG , 3UN ( 9UAN * 3HEN 3' 7ANG 8 ! NOVEL mAP WITH STRATEGICALLY PLACED SUTURES &IG METHOD OF COMPUTER AIDED ORTHOGNATHIC SURGERY USING INDIVIDUAL #!$#!- TEMPLATES ! COMBINATION OF OSTE !T THIS POINT IF REQUIRED WE MODIFY THE NASAL TIP OTOMY AND REPOSITIONING GUIDES Br J Oral Maxillofac Surg BY OPEN RHINOPLASTY 3IMILARLY IF CARTILAGE GRAFTS ARE EnE REQUIRED FOR THE NASAL DORSUM OR GRAFTS OR LOCAL PLASTY 4ANG - 'EDDES #2 9ANG $ -ORRIS 3& -ODIlED LEAD TO RELEASE THE NOSTRILS RECONSTRUCTION IS PERFORMED OXIDE GELATIN INJECTION TECHNIQUE FOR VASCULAR STUDIES J Clin 4HESE WELL VASCULARIZED AREAS ARE OPTIMAL FOR Anat n RECONSTRUCTING A SEPTAL DEFECT BECAUSE THEY COMPRISE
82e 6OLUME .UMBER s 6IEWPOINTS
DISCLOSURE The authors have no financial interest to declare in rela- tion to the content of this article.
PATIENT CONSENT The patient provided written consent for the use of her images.
REFERENCES !NDRÏ 2& ,OHUIS 0* 6UYK ($ .ASAL SEPTUM PERFORATION REPAIR USING DIFFERENTLY DESIGNED BILATERAL INTRANASAL mAPS WITH NONOPPOSING SUTURE LINES J Plast Reconstr Aesthet Surg Fig. 1. Raised perforator fap. n -ARSHALL $- !MJAD ) 7OLFE 3! 5SE OF THE RADIAL FOREARM mAP FOR DEEP CENTRAL MIDFACIAL DEFECTS Plast Reconstr Surg n DISCUSSION 0RIBAZ * 3TEPHENS 7 #RESPO , 'IFFORD ' ! NEW INTRAORAL mAP &ACIAL ARTERY MUSCULOMUCOSAL &!-- mAP Plast Recon- str Surg n :HAO : ,I 3 9AN 9 ET AL .EW BUCCINATOR MYOMUCOSAL ISLAND mAP !NATOMIC STUDY AND CLINICAL APPLICATION Plast Reconstr Surg n #ORONEL "ANDA -% 3ERRA 2ENOM *- ,ORENTE - ET AL #HEEK MUCOSA TERRITORIES IRRIGATED BY PERFORATORS FROM THE FACIAL ARTERY !N ANATOMICAL STUDY 3UBMITTED FOR PUBLICATION
Efficacy of the Buccal Fat Pad Graft in Facial Reconstruction and Aesthetic Augmentation Sir: Fig. 2. Flap inserted in the opening in the septum. MALL FACIAL SOFT TISSUE CONTOUR DEFORMITIES ARE SUSUALLY CORRECTED VIA THE TRANSFER OF AUTOGENOUS LIPOASPIRATE DUE TO THE SMALL VOLUMES AND PRECISION MUCOSA THE mAP IS RELATIVELY THIN AND THEIR PERFU REQUIRED 4HE POPULAR USE OF LIPOASPIRATE IS NOT WITH SION IS WELL DETERMINED 4HIS PROCEDURE GUARANTEES AN OUT COMPLICATIONS INCLUDING VOLUME RESORPTION DIFl EXCELLENT RESULT PROVIDED THAT THE PATIENT GIVES UP HIS CULTY IN ACHIEVING A THREE DIMENSIONAL CONFORMATIONAL OR HER COCAINE HABIT SHAPE AND THE POSSIBILITY OF FAT EMBOLISM 4HE MAIN $/) PRS REASON FOR DELAYED ABSORPTION OF ASPIRATE IS WELL KNOWN Mauricio E. Coronel-Banda, M.D. TO BE TRAUMA DURING THE ASPIRATION PROCEDURE 5NIVERSITAT )NTERNACIONAL DE #ATALUNYA )N THIS ARTICLE WE INTRODUCE THE FREE BUCCAL FAT PAD #ATALUNYA 3PAIN GRAFT AS AN ALTERNATIVE TO CORRECT THESE SMALL VOLUME FACIAL DEFORMITIES "ECAUSE THE FAT STRUCTURE IS WELL José Maria Serra-Mestre, M.D. PRESERVED IT IS ABLE TO MAINTAIN ITS VOLUME AND CONSIS 3ECOND 5NIVERSITY OF .APLES TENCY 4HE ANATOMY OF THE BUCCAL FAT PAD SHOULD BE WELL .APLES )TALY UNDERSTOOD IN ORDER TO MINIMIZE DONOR SITE COMPLICA TIONS AND ENSURE MINIMAL DAMAGE TO THE lNE LOBULAR José Maria Serra-Renom, M.D., Ph.D. ARCHITECTURE OF THE FAT PAD 5NIVERSITAT )NTERNACIONAL DE #ATALUNYA 4HE BUCCAL FAT PAD GRAFT IS HARVESTED VIA A SINGLE #ATALUNYA 3PAIN INTRAORAL BUCCAL INCISION 4HE OPENING OF 3TENSONS DUCT IS IDENTIlED AND THE BUCCAL INCISION IS PLACED Wendy P. Larrea-Terán, M.D., M.Sc. AWAY FROM THE DUCT ORIlCE AT THE LEVEL OF THE MANDIBU 5NIVERSIDAD #OMPLUTENSE DE -ADRID LAR OCCLUSAL LINE 4HE BUCCINATOR MUSCLE IS SPLIT USING -ADRID 3PAIN BLUNT DISSECTION AND THE ENCAPSULATED BUCCAL FAT PAD IS #ORRESPONDENCE TO $R 3ERRA -ESTRE DELIVERED WITH EXTERNAL DIGITAL PRESSURE #ARE IS TAKEN $EPARTMENT OF 0LASTIC AND 2ECONSTRUCTIVE 3URGERY TO AVOID DAMAGING THE CAPSULE OF THE FAT PAD 3ECOND 5NIVERSITY OF .APLES !LL CASES WERE PERFORMED BY A SINGLE SURGEON .APLES )TALY 4ABLE 4HERE WERE NO DONOR SITE COMPLICATIONS JMSERRAMESTRE GMAILCOM 4HERE WERE NO CASES OF CHEEK CONTOUR DEFORMITY !LL
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